**Section 2**

**Treatment Approach** 

166 Low Back Pain

Tekin, Y.; Ortancil, O.; Ankarali, H.; Basaran, A.; Sarikaya, S. & Ozdolap, S. (2009). Biering-Sorensen test scores in coal miners. *Joint Bone Spine,* Vol.76, No.3, pp. 281-285. Thomas, J.S.; France, C.R.; Sha, D. & Wiele, N.V. (2008). The influence of pain-related fear on

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Verbunt, J.A.; Smeets, R.J. & Wittink, H.M. (2010). Cause or effect? Deconditioning and

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**8** 

*Spain* 

**Physiotherapy Treatment on** 

A.I. Cuesta-Vargas, M. González-Sánchez,

M.T. Labajos-Manzanares and A. Galán-Mercant

**Chronic Non Specific Low Back Pain** 

*Department of Psychiatry and Physiotherapy, University of Malaga,* 

While it is true that back pain is defined as pain or discomfort located in the bottom of the ribcage and the top edge of the buttock, based on the time course in which you are (acute, subacute or chronic), how to act on them, bound to have different approaches for a

With regard to the different methods of intervention it has to comment that much has been said for years about the effect of bed rest as a strategy for improving low back pain symptoms. However, it was found that is equal or less effective than a placebo treatment or no treatment and may become a risk for chronicity process from acute low back pain 1-8.

By contrast, an active lifestyle, seems to favor the reduction of pain, time to return to work and disability rather than bed rest. It has also been shown to maintain this level of activity promotes a faster recovery, reducing the risk of relapse and more chronic pathology. However, when attempting to go beyond the trigger level, introducing therapeutic exercises as part of treatment, we observe that the results are equal to or worse than any other conservative treatment1,8-11. Moreover, therapeutic exercise is not advised in many clinical practice guidelines from different countries as a means of intervention in the early stages of

On the other hand, the use of analgesics in clinical practice guidelines from different states, we recommend the use of paracetamol and NSAIDs (in that order) 1,3,17-19 for the treatment of acute low back pain, suggesting the use of muscle relaxants in cases where the other two

There is a slight controversy regarding the use of spinal manipulation as a mode of intervention in acute low back pain, as it is not entirely clear whether or not it is advisable to use in this state of pathology22. Faced with such an open debate, we understand that it would be necessary to analyze each case individually so far there is consensus in the way of

On the other hand, there are two very well-identified interventions that suggest they are used as a treatment to be performed in a second stage of acute low back pain (LBP sub-

**1. Introduction** 

maximization of results.

low back pain episode1,3,4,12-16.

intervention.

types of drugs have not been effective20,21.

**1.1 Physiotherapy in acute low back pain** 

### **Physiotherapy Treatment on Chronic Non Specific Low Back Pain**

A.I. Cuesta-Vargas, M. González-Sánchez, M.T. Labajos-Manzanares and A. Galán-Mercant *Department of Psychiatry and Physiotherapy, University of Malaga, Spain* 

#### **1. Introduction**

#### **1.1 Physiotherapy in acute low back pain**

While it is true that back pain is defined as pain or discomfort located in the bottom of the ribcage and the top edge of the buttock, based on the time course in which you are (acute, subacute or chronic), how to act on them, bound to have different approaches for a maximization of results.

With regard to the different methods of intervention it has to comment that much has been said for years about the effect of bed rest as a strategy for improving low back pain symptoms. However, it was found that is equal or less effective than a placebo treatment or no treatment and may become a risk for chronicity process from acute low back pain 1-8.

By contrast, an active lifestyle, seems to favor the reduction of pain, time to return to work and disability rather than bed rest. It has also been shown to maintain this level of activity promotes a faster recovery, reducing the risk of relapse and more chronic pathology. However, when attempting to go beyond the trigger level, introducing therapeutic exercises as part of treatment, we observe that the results are equal to or worse than any other conservative treatment1,8-11. Moreover, therapeutic exercise is not advised in many clinical practice guidelines from different countries as a means of intervention in the early stages of low back pain episode1,3,4,12-16.

On the other hand, the use of analgesics in clinical practice guidelines from different states, we recommend the use of paracetamol and NSAIDs (in that order) 1,3,17-19 for the treatment of acute low back pain, suggesting the use of muscle relaxants in cases where the other two types of drugs have not been effective20,21.

There is a slight controversy regarding the use of spinal manipulation as a mode of intervention in acute low back pain, as it is not entirely clear whether or not it is advisable to use in this state of pathology22. Faced with such an open debate, we understand that it would be necessary to analyze each case individually so far there is consensus in the way of intervention.

On the other hand, there are two very well-identified interventions that suggest they are used as a treatment to be performed in a second stage of acute low back pain (LBP sub-

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 171

85% of low back pain who are diagnosed are performed without an objective test anatomical/radiological abnormality detected28,29. People suffering from this disorder suffer

Optimal treatment remains a great mystery, but there are some randomized trials suggest some improvement of which is scientifically proven. Nevertheless, it was found that people with LBP, have impaired motor control, which varies greatly depending on each person30. The approach is now more accepted in the scientific community is one that is based on the diagnosis for a classical determination, noting how the loss of motor control itself or as a

This diagnostic process places great emphasis on the conclusion between the subject's history, radiology, pain behavior, physical examination findings as well as significant pathology (red flags) and psychological (yellow flags), including negative beliefs, stress

One of the key that has changed the concept of LBP is to observe the musculoskeletal imbalance from a bio-psycho-social, which is currently accepted and widespread. So based

Group 1: subjects whose response is adapted motor control and is secondary to an

Group 2: subjects with secondary response is due to a psychological and / or social, not

Group 3: subjects that offer a maladaptive response following a load on the tissue that is

On the other hand, Dankaers (2011)31 has identified some distinct patterns based on the direction where the motion is lost, where motor control is working properly motor control. This identifies the inflection patterns, active and passive extension, lateral tilt and multidirectional patterns. It has also been demonstrated as well-trained physiotherapists and doctors are able to differentiate the subjects and subclassified into these different groups.

Physiotherapy or physical therapy is a health science dedicated to study the life, health, illness and death of human beings from the standpoint of human body movement. It's characterized by search for the proper development of functions that produce the body's systems, where his performance good or bad, affects the human body or kinetic movement. It Intervene when human beings have lost or are at risk of losing or alter temporarily or permanently the proper motion and thus physical function by using scientifically proven

The World Health Organization (WHO) defines physical therapy in 1958 as "the science of treatment through: physical, therapeutic exercise, massage and electrotherapy. In addition, the Physiotherapy involves performing electrical tests and manuals to determine the value of involvement and muscle strength tests to determine functional abilities, range of joint movement and vital capacity measures and diagnostic aids for the control of evolution".

on this approach, this motor response can be classified into three distinct groups32:

**1.2 Low back pain clasifications** 

result of secondary pathology.

anxiety, catastrophizing, depression31,32, ...

underlying disease process.

abnormal and leads to ongoing pain and anguish.

**1.3 Physiotherapy in chronic low back pain** 

organic.

techniques.

musculoskeletal LBP.

acute) aimed at preventing chronicity more than the relief of symptoms of acute low back pain. These two modes of intervention are back school and multidisciplinary treatments1,2325.

Thus, in acute low back pain, it is observed at the base of treatment are three aspects that are crucial for clinical success:


#### **1.1.1 Identifiers in acute chronic low back pain**

As defined, low back pain was defined as pain or discomfort that is located between the bottom of the ribs and the top of the buttocks, with or without radiation to the lower limbs. As in other musculoskeletal disorders, there are three stages of low back pain attending to issues of temporality, acute, subacute and chronic.

There have been several studies whose aim was to identify those signs or variables that may help predict a patient's eventual evolution toward chronicity. To this end, the authors have been gradually moving away from the biomedical model to observe the patient from a broader perspective, the bio-psycho-social.

In literature, there is a lot of factors that may influence patients with acute LBP, however, have identified a number of them appear to be correlated with increased likelihood of more chronic musculoskeletal this pathology. These factors, mainly psychological and occupational, have proved more reliable as predictors of chronic low back pain. These indicators, identified by Melloh et al. (2008)27 (Figure 1) should be taken into account by professional therapists and clinicians working with these patients and include them as areas that should be involved in the treatment plan.


Image 1. predictors of chronicity by Melloh.

#### **1.2 Low back pain clasifications**

170 Low Back Pain

acute) aimed at preventing chronicity more than the relief of symptoms of acute low back pain. These two modes of intervention are back school and multidisciplinary treatments1,2325. Thus, in acute low back pain, it is observed at the base of treatment are three aspects that are

 One is to provide the patient with adequate information, an overemphasis on the fact that back pain is not too serious problem, the evolution in most cases the evolution is directed toward a rapid recovery and return to daily life . In this part of treatment is recommended to make it easier for the patient increase awareness about your pain, trying to be supportive and helps to eliminate the negative stigma of this disease skeletal muscle. This will important that there is consistency in message among all

Advise patient to try to keep an active lifestyle and return to normal life, including his

As defined, low back pain was defined as pain or discomfort that is located between the bottom of the ribs and the top of the buttocks, with or without radiation to the lower limbs. As in other musculoskeletal disorders, there are three stages of low back pain attending to

There have been several studies whose aim was to identify those signs or variables that may help predict a patient's eventual evolution toward chronicity. To this end, the authors have been gradually moving away from the biomedical model to observe the patient from a

In literature, there is a lot of factors that may influence patients with acute LBP, however, have identified a number of them appear to be correlated with increased likelihood of more chronic musculoskeletal this pathology. These factors, mainly psychological and occupational, have proved more reliable as predictors of chronic low back pain. These indicators, identified by Melloh et al. (2008)27 (Figure 1) should be taken into account by professional therapists and clinicians working with these patients and include them as areas

• Characteristics or working conditions.

• Impact on the role or on DLA.

• Strategies of response to pain. • Fear of beliefs about the disease. • Social or emotional support.

• Issues related to pain. • Medical considerations.

• Depression.

crucial for clinical success:

clinicians who work with the patient. Provide adequate control of symptoms.

**1.1.1 Identifiers in acute chronic low back pain** 

issues of temporality, acute, subacute and chronic.

broader perspective, the bio-psycho-social.

that should be involved in the treatment plan.

Image 1. predictors of chronicity by Melloh.

working life as soon as possible.

85% of low back pain who are diagnosed are performed without an objective test anatomical/radiological abnormality detected28,29. People suffering from this disorder suffer musculoskeletal LBP.

Optimal treatment remains a great mystery, but there are some randomized trials suggest some improvement of which is scientifically proven. Nevertheless, it was found that people with LBP, have impaired motor control, which varies greatly depending on each person30.

The approach is now more accepted in the scientific community is one that is based on the diagnosis for a classical determination, noting how the loss of motor control itself or as a result of secondary pathology.

This diagnostic process places great emphasis on the conclusion between the subject's history, radiology, pain behavior, physical examination findings as well as significant pathology (red flags) and psychological (yellow flags), including negative beliefs, stress anxiety, catastrophizing, depression31,32, ...

One of the key that has changed the concept of LBP is to observe the musculoskeletal imbalance from a bio-psycho-social, which is currently accepted and widespread. So based on this approach, this motor response can be classified into three distinct groups32:


On the other hand, Dankaers (2011)31 has identified some distinct patterns based on the direction where the motion is lost, where motor control is working properly motor control. This identifies the inflection patterns, active and passive extension, lateral tilt and multidirectional patterns. It has also been demonstrated as well-trained physiotherapists and doctors are able to differentiate the subjects and subclassified into these different groups.

#### **1.3 Physiotherapy in chronic low back pain**

Physiotherapy or physical therapy is a health science dedicated to study the life, health, illness and death of human beings from the standpoint of human body movement. It's characterized by search for the proper development of functions that produce the body's systems, where his performance good or bad, affects the human body or kinetic movement. It Intervene when human beings have lost or are at risk of losing or alter temporarily or permanently the proper motion and thus physical function by using scientifically proven techniques.

The World Health Organization (WHO) defines physical therapy in 1958 as "the science of treatment through: physical, therapeutic exercise, massage and electrotherapy. In addition, the Physiotherapy involves performing electrical tests and manuals to determine the value of involvement and muscle strength tests to determine functional abilities, range of joint movement and vital capacity measures and diagnostic aids for the control of evolution".

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 173

back pain should have a history and examination that should be performed in acute and subacute stages of the disease. However, a clinical examination should be performed also in the chronic phase, the first objective should focus on the location of calls red flags, to access the yellow flags and then make a specific diagnosis. However, it is well accepted that low back pain, sometimes it is not possible to reach a diagnosis based on the pathological changes detected, because too many diagnostic systems have been proposed in which back pain is categorized based on the distribution of pain, pain behaviour, clinical signs,

The aspect that has to be prioritized is to ensure that the pain is musculoskeletal in origin. The next step is to exclude the presence of specific pathologies of the spine. While the first suspect should appear in the medical history, we can get confirmation of the diagnosis through a thorough analysis of the individual33. The red flags such as neoplasms, infections, the syndrome of the cauda equina (cauda equina) are often difficult to find at this stage of the disease, however it is important to rule out a priori any of these options. The examiner should have sufficient knowledge to detect and diagnose major structural changes, deformities and serious spinal conditions. The patient should help the therapist to identify the type of pain and suffering the distribution. Clinical examination should provide confirmation that the patient complains of symptoms. If this were not the case, the type of pain should be classified as non-specific. It is also important to identify psychosocial yellow flags calls because they are factors that increase the risk of developing or perpetuating chronic pain, lengthening the time of disability suffered by the patient and, eventually, loss of working days the symptoms associated with produced by low back pain. Within these warning signs should be included inadequate skills in reference to back pain, (such as the patient to override a passive treatment by understanding that the assets will be lower), inappropriate behavior in terms of pain, being afraid to move and thus to progressively reduce the level of activity, work-related problems such as low job satisfaction or emotional

It is recommended that the diagnosis of triage in the first assessment and subsequent reassessments to exclude specific pathologies of the spine and nerve root. However, it seems advisable not spinal palpation and the use of motion tests in the diagnosis of low back pain. This recommendation is based on moderate evidence exists about the validity of the test of straight leg raising. This same level of evidence would say that there is no single test that has high sensitivity and specificity in the diagnosis of ankylosing spondylitis, a radiculopathy or spinal cancer. On the other hand, always based on moderate evidence, one could say that the pain provocation tests are more reliable than palpation tests. This has not been established as valid and reliable palpation tests, provided they are used for diagnosis,

Images are often used in patients with low back pain radicular pain assessment or identify any signs of serious alarm (red flag) and objective. The most common tests of diagnostic imaging in primary care centers usually plain radiography, bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). In general, the reference to the

problems may be clear examples of psychosocial yellow flags34.

the presence of a manipulable lesion remains hypothetical35,36.

disability, ecc33.

**2.3 Physical examination** 

**2.4 Further exploration** 

Given this reality, this discipline would possess all the credentials to treat low back pain from a conservative viewpoint successfully and safely. However, it is necessary to consider the spectrum of affection from low back pain that this disease does not always present a homogenous condition, but the severity of the condition may limit the person slightly, since this would suffer localized pain, or much more severe, preventing it to perform any work activity, with significant socioeconomic implications, particularly in developed countries. This musculoskeletal problem has an impact on many aspects of the person, such as quality of life, mobility, more likely to suffer long-term diseases, increased risk of social exclusion due to an inability to work, reduced income, isolation due to social disability.

Thus, low back pain is presented as a pathology that can be a considerable burden on the individual, their families, society and the economy (through loss of working days, or even the need to apply for retirement advance). Given this reality, the objectives of interventions and conservative treatments carried out through physical therapy, should be oriented towards reducing the symptoms of this dysfunction, such as pain management and disability, reducing anxiety states, trying to minimize the risk of recurrence and the time required for re-entry into the work.

This discipline has innumerable health tools that can be understood as a means of intervention in patients with chronic musculoskeletal disorders in general and low back pain in particular. This intervention strategies which a therapist can use are numerous: therapies, cognitive therapies that help pain management, complementary therapies, orthotics, physical therapy, electrotherapy, exercise, education, back school, some treatments invasive, such as acupuncture or postural ergonomics, for example.

While all of these alternative therapies are an option a priori for this clinician, not all these methods of intervention are equally effective. So this chapter will attempt to make a proposal for intervention based on scientific evidence demonstrating the effectiveness of each of the chosen methodologies, prompting the therapist to perform an exercise of reflection and selection techniques that may be more effective in their daily practice.

#### **2. Patient assessment, diagnosis, prognosis and treatment: Clinical history**

#### **2.1 Introduction**

An initial assessment can clarify the diagnosis of chronic low back pain or less. In the physical therapy a way that is nonspecific, ie not caused by a diagnosed disease, such as cancer, fracture, ankylosing spondylitis or other inflammation, though hardly reach the specific lumbalcias exceed six weeks of evolution, as is usually the early diagnosis of the cause of it.

#### **2.2 History**

For a complete patient assessment, it is important an adequate and exhaustive examination. The correct diagnosis depends on knowledge of functional anatomy, an accurate history of the patient, diligent observation and a complete examination. Accurate diagnosis is only established by a comprehensive assessment that includes the above factors. The purpose of the assessment must be to understand fully and clearly the patient's problems and the physical basis of the symptoms that cause them discomfort. All patients with chronic low

Given this reality, this discipline would possess all the credentials to treat low back pain from a conservative viewpoint successfully and safely. However, it is necessary to consider the spectrum of affection from low back pain that this disease does not always present a homogenous condition, but the severity of the condition may limit the person slightly, since this would suffer localized pain, or much more severe, preventing it to perform any work activity, with significant socioeconomic implications, particularly in developed countries. This musculoskeletal problem has an impact on many aspects of the person, such as quality of life, mobility, more likely to suffer long-term diseases, increased risk of social exclusion

Thus, low back pain is presented as a pathology that can be a considerable burden on the individual, their families, society and the economy (through loss of working days, or even the need to apply for retirement advance). Given this reality, the objectives of interventions and conservative treatments carried out through physical therapy, should be oriented towards reducing the symptoms of this dysfunction, such as pain management and disability, reducing anxiety states, trying to minimize the risk of recurrence and the time

This discipline has innumerable health tools that can be understood as a means of intervention in patients with chronic musculoskeletal disorders in general and low back pain in particular. This intervention strategies which a therapist can use are numerous: therapies, cognitive therapies that help pain management, complementary therapies, orthotics, physical therapy, electrotherapy, exercise, education, back school, some

While all of these alternative therapies are an option a priori for this clinician, not all these methods of intervention are equally effective. So this chapter will attempt to make a proposal for intervention based on scientific evidence demonstrating the effectiveness of each of the chosen methodologies, prompting the therapist to perform an exercise of

due to an inability to work, reduced income, isolation due to social disability.

treatments invasive, such as acupuncture or postural ergonomics, for example.

reflection and selection techniques that may be more effective in their daily practice.

**2. Patient assessment, diagnosis, prognosis and treatment: Clinical history** 

An initial assessment can clarify the diagnosis of chronic low back pain or less. In the physical therapy a way that is nonspecific, ie not caused by a diagnosed disease, such as cancer, fracture, ankylosing spondylitis or other inflammation, though hardly reach the specific lumbalcias exceed six weeks of evolution, as is usually the early diagnosis of the

For a complete patient assessment, it is important an adequate and exhaustive examination. The correct diagnosis depends on knowledge of functional anatomy, an accurate history of the patient, diligent observation and a complete examination. Accurate diagnosis is only established by a comprehensive assessment that includes the above factors. The purpose of the assessment must be to understand fully and clearly the patient's problems and the physical basis of the symptoms that cause them discomfort. All patients with chronic low

required for re-entry into the work.

**2.1 Introduction** 

cause of it.

**2.2 History** 

back pain should have a history and examination that should be performed in acute and subacute stages of the disease. However, a clinical examination should be performed also in the chronic phase, the first objective should focus on the location of calls red flags, to access the yellow flags and then make a specific diagnosis. However, it is well accepted that low back pain, sometimes it is not possible to reach a diagnosis based on the pathological changes detected, because too many diagnostic systems have been proposed in which back pain is categorized based on the distribution of pain, pain behaviour, clinical signs, disability, ecc33.

The aspect that has to be prioritized is to ensure that the pain is musculoskeletal in origin. The next step is to exclude the presence of specific pathologies of the spine. While the first suspect should appear in the medical history, we can get confirmation of the diagnosis through a thorough analysis of the individual33. The red flags such as neoplasms, infections, the syndrome of the cauda equina (cauda equina) are often difficult to find at this stage of the disease, however it is important to rule out a priori any of these options. The examiner should have sufficient knowledge to detect and diagnose major structural changes, deformities and serious spinal conditions. The patient should help the therapist to identify the type of pain and suffering the distribution. Clinical examination should provide confirmation that the patient complains of symptoms. If this were not the case, the type of pain should be classified as non-specific. It is also important to identify psychosocial yellow flags calls because they are factors that increase the risk of developing or perpetuating chronic pain, lengthening the time of disability suffered by the patient and, eventually, loss of working days the symptoms associated with produced by low back pain. Within these warning signs should be included inadequate skills in reference to back pain, (such as the patient to override a passive treatment by understanding that the assets will be lower), inappropriate behavior in terms of pain, being afraid to move and thus to progressively reduce the level of activity, work-related problems such as low job satisfaction or emotional problems may be clear examples of psychosocial yellow flags34.

#### **2.3 Physical examination**

It is recommended that the diagnosis of triage in the first assessment and subsequent reassessments to exclude specific pathologies of the spine and nerve root. However, it seems advisable not spinal palpation and the use of motion tests in the diagnosis of low back pain. This recommendation is based on moderate evidence exists about the validity of the test of straight leg raising. This same level of evidence would say that there is no single test that has high sensitivity and specificity in the diagnosis of ankylosing spondylitis, a radiculopathy or spinal cancer. On the other hand, always based on moderate evidence, one could say that the pain provocation tests are more reliable than palpation tests. This has not been established as valid and reliable palpation tests, provided they are used for diagnosis, the presence of a manipulable lesion remains hypothetical35,36.

#### **2.4 Further exploration**

Images are often used in patients with low back pain radicular pain assessment or identify any signs of serious alarm (red flag) and objective. The most common tests of diagnostic imaging in primary care centers usually plain radiography, bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). In general, the reference to the

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 175

argue with strong evidence that workers who suffer acute back pain and work in places where they have to bend over constantly, have a higher risk of more chronic such alteration. Also, with the same degree of evidence, one could argue that people with low back pain for at least 4 weeks, have more trouble working back to normal and the lower the effectiveness

It can be said, moreover, that there is moderate evidence that specific evidence of the physical examination are of great prognostic value in chronic low back pain Thus, a prognosis of evolution of acute low back pain sub-acute to chronic, with moderate evidence, there are greater expectations of this happening when the patient psychosocial distress, depressive mood, severity of pain and functional impact and extreme symptom report, patient expectations, and previous episodes of back pain. And also maintaining the level of evidence could be considered predictors of chronicity the shorter length of labor, radicular

In a patient who suffers chronic back pain, a physiotherapist must do an exercise of reflection and try to plan your intervention based on two fundamental aspects: the symptomatological and functional. This could open a small internal debate about what should the clinician prioritize and possess both relative and absolute importance very

The wide range of therapeutic options held by the therapist, makes the customization of treatment as long as possible, should be a priority to tackling and improve musculoskeletal

As has been shown that chronic musculoskeletal involvement has a spectrum of influence that goes far beyond his own person, with repercussions on the family, society and employment. This problem should not go unnoticed by the physiotherapist and delegate, as far as possible in other health professionals if the situation closely, try to give a solution born of the subject and affect their environment but also to walk the opposite direction, the

In recent years, the use of ultrasound (U.S.) has been progressively extended, due to its economy, reliability, relative ease of use and accessibility. Specifically in the back, although it has shown the importance of the deep back muscles by neurophysiological and biomechanical. Ultrasound is gradually taking a greater presence and are identifying themselves as a very useful tool for the assessment and treatment of patients with low back

This instrument has been used for quantitative assessments using static and dynamic images to understand the morphology and behavior during muscle contraction on both parasespinal and abdominal belt muscles. They have observed changes in muscle architecture based on the intensity and duration of the contraction, allowing use by a researcher to analyze the behavior of muscle as well as instruments of feedback to the

of clinicians when the patient been absent during that period of his job.

or performing heavy work without modification35.

disorder that led to that person to the therapist.

environment impact on the subject itself.

**2.8 Ultrasound and low back pain** 

**2.7 Physiotherapy treatment** 

important.

pain41-47.

patient49,50.

image must be based on a specific indication, although it is true that sometimes the patient arrives at the physical therapist once you have completed all the diagnostic tests, but it has the opportunity to participate in this regard37-39.

Of all diagnostic tests, radiography, its low cost and availability, is the most common, from a front, rear or side. This test allows us to precisely analyze the vertebral body height, alignment of the disc, and other morphological aspects of bone, however limited it to perform an analysis of the soft tissue structures. So despite the fact that other perspectives would be useful in the diagnosis of other rheumatic diseases, for diagnosis of low back pain, radiography would not be the best option, as it only allows an assessment of structural alterations40.

For the evaluation of the warning signs of soft tissue, MRI is the best option for the precision it offers, in addition to be suffering a slow but steady expansion which makes it more and more evidence is available39.

#### **2.5 Physiotherapy diagnosis**

A diagnosis is a common task for all healthcare professionals involved in treating patients, not just doctors, and in itself is not a medical act. The medical diagnosis is an important element but is not sufficient information to direct the physiotherapist. Physiotherapy diagnosis is an opinion based on rational critical analysis of all available information. It is imprencindible, therefore the incorporation of an evaluation, analysis and interpretation, own of the physiotherapist to guide him /her in planning therapeutic interventions, prevention and education and / or training the patient or user of their services. It is not, as the aforementioned decision, to "diagnose illnesses," it is an exclusive competence of the physician36.

The physiotherapist has an important role in the functionality of the neuro - musculo – skeletal system and will need further evaluation within this framework. Thus, physiotherapy diagnosis should be formulated from the significant data on the patient's problems, as reflected in the common history. This history bio-psycho-social help each multidisciplinary team with the patient care. In addition and from a specific perspective, the diagnosis should be based also on an examination or assessment to assess the level of functional impairment of the patient as well as an explanation for the origin of such involvement.

Professional practice in physiotherapy involves processes and procedures among which the evaluation process, through which the therapist organizes its resources to learn and understand the patient's health condition from a motor and functional36.

#### **2.6 Prognosis**

When speaking of prognosis in patients with low back pain, it is necessary to refer to those factors that help predict the evolution of the pathology and, therefore, those variables that help to predict future trends or events such as the return to work, the cost of the intervention, disability or the evolution of pain the patient suffers. Among these factors, the individual character and psychosocial professionals play an important role in the persistence of symptoms and disability. Thus, after analyzing several studies, one could argue with strong evidence that workers who suffer acute back pain and work in places where they have to bend over constantly, have a higher risk of more chronic such alteration. Also, with the same degree of evidence, one could argue that people with low back pain for at least 4 weeks, have more trouble working back to normal and the lower the effectiveness of clinicians when the patient been absent during that period of his job.

It can be said, moreover, that there is moderate evidence that specific evidence of the physical examination are of great prognostic value in chronic low back pain Thus, a prognosis of evolution of acute low back pain sub-acute to chronic, with moderate evidence, there are greater expectations of this happening when the patient psychosocial distress, depressive mood, severity of pain and functional impact and extreme symptom report, patient expectations, and previous episodes of back pain. And also maintaining the level of evidence could be considered predictors of chronicity the shorter length of labor, radicular or performing heavy work without modification35.

#### **2.7 Physiotherapy treatment**

174 Low Back Pain

image must be based on a specific indication, although it is true that sometimes the patient arrives at the physical therapist once you have completed all the diagnostic tests, but it has

Of all diagnostic tests, radiography, its low cost and availability, is the most common, from a front, rear or side. This test allows us to precisely analyze the vertebral body height, alignment of the disc, and other morphological aspects of bone, however limited it to perform an analysis of the soft tissue structures. So despite the fact that other perspectives would be useful in the diagnosis of other rheumatic diseases, for diagnosis of low back pain, radiography would not be the best option, as it only allows an assessment of structural

For the evaluation of the warning signs of soft tissue, MRI is the best option for the precision it offers, in addition to be suffering a slow but steady expansion which makes it more and

A diagnosis is a common task for all healthcare professionals involved in treating patients, not just doctors, and in itself is not a medical act. The medical diagnosis is an important element but is not sufficient information to direct the physiotherapist. Physiotherapy diagnosis is an opinion based on rational critical analysis of all available information. It is imprencindible, therefore the incorporation of an evaluation, analysis and interpretation, own of the physiotherapist to guide him /her in planning therapeutic interventions, prevention and education and / or training the patient or user of their services. It is not, as the aforementioned decision, to "diagnose illnesses," it is an exclusive competence of the

The physiotherapist has an important role in the functionality of the neuro - musculo – skeletal system and will need further evaluation within this framework. Thus, physiotherapy diagnosis should be formulated from the significant data on the patient's problems, as reflected in the common history. This history bio-psycho-social help each multidisciplinary team with the patient care. In addition and from a specific perspective, the diagnosis should be based also on an examination or assessment to assess the level of functional impairment of the patient as well as an explanation for the origin of such

Professional practice in physiotherapy involves processes and procedures among which the evaluation process, through which the therapist organizes its resources to learn and

When speaking of prognosis in patients with low back pain, it is necessary to refer to those factors that help predict the evolution of the pathology and, therefore, those variables that help to predict future trends or events such as the return to work, the cost of the intervention, disability or the evolution of pain the patient suffers. Among these factors, the individual character and psychosocial professionals play an important role in the persistence of symptoms and disability. Thus, after analyzing several studies, one could

understand the patient's health condition from a motor and functional36.

the opportunity to participate in this regard37-39.

alterations40.

physician36.

involvement.

**2.6 Prognosis** 

more evidence is available39.

**2.5 Physiotherapy diagnosis** 

In a patient who suffers chronic back pain, a physiotherapist must do an exercise of reflection and try to plan your intervention based on two fundamental aspects: the symptomatological and functional. This could open a small internal debate about what should the clinician prioritize and possess both relative and absolute importance very important.

The wide range of therapeutic options held by the therapist, makes the customization of treatment as long as possible, should be a priority to tackling and improve musculoskeletal disorder that led to that person to the therapist.

As has been shown that chronic musculoskeletal involvement has a spectrum of influence that goes far beyond his own person, with repercussions on the family, society and employment. This problem should not go unnoticed by the physiotherapist and delegate, as far as possible in other health professionals if the situation closely, try to give a solution born of the subject and affect their environment but also to walk the opposite direction, the environment impact on the subject itself.

#### **2.8 Ultrasound and low back pain**

In recent years, the use of ultrasound (U.S.) has been progressively extended, due to its economy, reliability, relative ease of use and accessibility. Specifically in the back, although it has shown the importance of the deep back muscles by neurophysiological and biomechanical. Ultrasound is gradually taking a greater presence and are identifying themselves as a very useful tool for the assessment and treatment of patients with low back pain41-47.

This instrument has been used for quantitative assessments using static and dynamic images to understand the morphology and behavior during muscle contraction on both parasespinal and abdominal belt muscles. They have observed changes in muscle architecture based on the intensity and duration of the contraction, allowing use by a researcher to analyze the behavior of muscle as well as instruments of feedback to the patient49,50.

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 177

Different scales have been used when classifying the different types of studies consulted. Thus, those involving an intervention, we used the proposed assessment by PEDro, which classifies studies according to internal validity on a scale of 0 to 10, which uses the following evaluation points, which add a point to the validity of the study for each one that is confirmed. The trials achieved a score equal to or greater than 5 were considered high

1. Subjects Were Allocated randomly to groups (in a crossover study, subjects randomly

3. Were the groups similar at baseline regarding the Most Important Prognostic Indicators

7. Measures of outcome at least one key Were Obtained from More Than 85% of the

8. All subjects for Whom Were available Outcome Measures The Treatment Received or Allocated as condition or control, where, This Was not the case, data for at least one key

9. The results of between-group Statistical Comparisons are at least one report for key

10. The study Provides Both point Measure and Measures of variability for at least one key

Thus, the quality of the methodology used in a systematic review (SR) was evaluated by Oxman and Guyatt index. On a scale of 0 to 7, those who scored higher than 5 were considered high quality, while its value was less than the index, were classified as low

Thus, it is classified according to levels of evidence based on evidence levels for the

• Level A (strong): the results are drawn from a high quality systematic review consists of

• Level B (moderate evidence): results of a systematic review consists of randomized

• Level C (limited or conflicting evidence): derived from a clinical trial (high or low

Thus, taking as base the strength of evidence consulted, there have been a series of statements in which roughly suggests the use of a particular methodology or intervention

 **Interferential Therapy**. Defined as the surface application of medium frequency alternating current to cause low frequencies to 150 Hz There is no evidence on the

Were Allocated an Treatments Which Were in order received)

5. There Was blinding of all therapists Who Administered the therapy.

6. There Was blinding of all Assessors Who Measured at least one key outcome.

**3.2 Evidence-Based Physiotherapy (EBP)** 

quality57. The criteria used were:

2. Allocation concealed WAS

outcome

outcome

quality.

technique.

4. There Was blinding of all subjects

subjects initially allocated to groups.

controlled trials (RCT) of low quality.

• Level D (without evidence): No RCTs were identified.

**3.3 Clinical evidence of physical agents in physiotherapy** 

outcome WAS analyze by "intention to treat"

treatments are classified according to the following classification58:

multiple randomized controlled trials (RCT) of high quality.

quality) or a systematic review of several RCT inconsistent results.

While there has been the usefulness of this instrument, it is important to consider the location, the positioning of the operator with respect to the patient to make a record and therefore a correct interpretation of the image51.

Studies on a static muscle is important for different important aspects of it, such as differences in the edges of the muscle, so that it can be studied by analyzing the relationship between cross-sectional area, and other aspects like morphology, subject's BMI, pennation angle, shape, thickness ... These same records can be made in the same way during both isometric and isotonic contraction, being able to see how it changes as the muscle changes the intensity of contraction, the time of the same or the angle of the two bones in which it is inserted49-52.

Ultrasound has proven to be a tool with reliability comparable to that of nuclear magnetic resonance, however, the latter does not have the ability to analyze the muscle during an isokinetic contraction. Reference has been used as electromyography, showing a curvilinear relationship on parameters that can be obtained with ultrasound, as the muscle thickness or pennation angle, so that it could be possible suggest the use of ultrasound, in both the clinical and research51.

#### **3. Evidence based physiotherapy: What are most effective interventions?**

#### **3.1 Introduction**

The evidence-based physiotherapy (EBP) is a current focus on teaching and health practice, which emphasizes the importance of examining the evidence from research, careful interpretation of clinical information derived from unsystematic observations, and where understanding of the pathophysiology of disease is insufficient for quality clinical practice53,54. "The practice of evidence-based physical therapy should be informed primarily by the research of high quality, patient preferences and knowledge of physical therapists"55.

Under the current definition of the FBE there are some additional factors that interact with the quality research, knowledge and practice of patient preferences, these factors are culture, politics, resources, ecc. So they are who will determine the specific context on which the decision applies.

The FBE clinical practice is an attempt to respond to this new situation, mainly through three strategies: learning methodology, the pursuit and implementation of abstracts and scientific information gathered by others and the acceptance of protocols and guidelines developed tested by third parties. The exercise of the FBE would not be such without the consideration of each situation and each scenario. On the other hand, the roles in the relationship between professionals and patients are variable, and there is a clear demand for direct participation of patients in decision making55.

The FBE can be applied in daily work with any type of physiotherapy intervention, whether diagnostic, therapeutic or preventive and may be a useful tool for assessing the results of these interventions (Herbert, 2000), because it helps optimize the time of professional application criteria can accumulate in different scenarios and / or patients, improving accessibility to information and helps to reduce uncertainty. Also, when our expertise and daily practice does not follow the recommendations of the literature, the decision finally will be more likely to adopt proven and reasoned. The suggestions will be stronger if one is aware of the extent and strength of recommendations regarding an intervention.

#### **3.2 Evidence-Based Physiotherapy (EBP)**

Different scales have been used when classifying the different types of studies consulted. Thus, those involving an intervention, we used the proposed assessment by PEDro, which classifies studies according to internal validity on a scale of 0 to 10, which uses the following evaluation points, which add a point to the validity of the study for each one that is confirmed. The trials achieved a score equal to or greater than 5 were considered high quality57. The criteria used were:


176 Low Back Pain

While there has been the usefulness of this instrument, it is important to consider the location, the positioning of the operator with respect to the patient to make a record and

Studies on a static muscle is important for different important aspects of it, such as differences in the edges of the muscle, so that it can be studied by analyzing the relationship between cross-sectional area, and other aspects like morphology, subject's BMI, pennation angle, shape, thickness ... These same records can be made in the same way during both isometric and isotonic contraction, being able to see how it changes as the muscle changes the intensity of contraction, the time of the same or the angle of the two bones in which it is

Ultrasound has proven to be a tool with reliability comparable to that of nuclear magnetic resonance, however, the latter does not have the ability to analyze the muscle during an isokinetic contraction. Reference has been used as electromyography, showing a curvilinear relationship on parameters that can be obtained with ultrasound, as the muscle thickness or pennation angle, so that it could be possible suggest the use of ultrasound, in both the

**3. Evidence based physiotherapy: What are most effective interventions?** 

The evidence-based physiotherapy (EBP) is a current focus on teaching and health practice, which emphasizes the importance of examining the evidence from research, careful interpretation of clinical information derived from unsystematic observations, and where understanding of the pathophysiology of disease is insufficient for quality clinical practice53,54. "The practice of evidence-based physical therapy should be informed primarily by the research of high quality, patient preferences and knowledge of physical therapists"55. Under the current definition of the FBE there are some additional factors that interact with the quality research, knowledge and practice of patient preferences, these factors are culture, politics, resources, ecc. So they are who will determine the specific context on which the

The FBE clinical practice is an attempt to respond to this new situation, mainly through three strategies: learning methodology, the pursuit and implementation of abstracts and scientific information gathered by others and the acceptance of protocols and guidelines developed tested by third parties. The exercise of the FBE would not be such without the consideration of each situation and each scenario. On the other hand, the roles in the relationship between professionals and patients are variable, and there is a clear demand for

The FBE can be applied in daily work with any type of physiotherapy intervention, whether diagnostic, therapeutic or preventive and may be a useful tool for assessing the results of these interventions (Herbert, 2000), because it helps optimize the time of professional application criteria can accumulate in different scenarios and / or patients, improving accessibility to information and helps to reduce uncertainty. Also, when our expertise and daily practice does not follow the recommendations of the literature, the decision finally will be more likely to adopt proven and reasoned. The suggestions will be stronger if one is

aware of the extent and strength of recommendations regarding an intervention.

therefore a correct interpretation of the image51.

inserted49-52.

clinical and research51.

**3.1 Introduction** 

decision applies.

direct participation of patients in decision making55.


Thus, the quality of the methodology used in a systematic review (SR) was evaluated by Oxman and Guyatt index. On a scale of 0 to 7, those who scored higher than 5 were considered high quality, while its value was less than the index, were classified as low quality.

Thus, it is classified according to levels of evidence based on evidence levels for the treatments are classified according to the following classification58:


Thus, taking as base the strength of evidence consulted, there have been a series of statements in which roughly suggests the use of a particular methodology or intervention technique.

#### **3.3 Clinical evidence of physical agents in physiotherapy**

 **Interferential Therapy**. Defined as the surface application of medium frequency alternating current to cause low frequencies to 150 Hz There is no evidence on the

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 179

 Massage: Soft tissue manipulation with the hands or a mechanical device through a variety of specific methods. As evidence, it seems that there is limited evidence when talking about the fact that massage causes on subjects suffering chronic back pain by saying that there is no difference between this technique and the use of a corset, that massage is more effective in symptomatological treatment of low back pain when compared to acupuncture, physical therapy, self-management education, the placebo treatment, postural education, relaxation therapy. There are also limited evidence that massage is as effective as manipulation in low back pain but, however, functional

As for the therapeutic exercise, there is moderate evidence that short-term improvements achieved over the reduction of pain and disability than passive treatments. There is strong evidence that treatment with therapeutic exercise is more effective than standard medical practice for both the reduction of pain, disability and the average time to return to work. This level of evidence is maintained when you try to say that strength training conditioning, there are more effective than other exercises in the treatment of chronic low

Massage is the technique used for longer physical therapists in history. Instinctive mode makes use has been used by almost every culture in history, like the Greeks and Romans (where, among other uses, was used to retrieve the athletes and gladiators, respectively, after the shows), the ancient Egypt, where priests were using it in conjunction with other therapeutic techniques and even in China, where emperors of the best massage therapists

Although massage is socially understood as a technique of intervention whose focus is the muscle, it must have a broader definition because it is the set of soft tissues the main beneficiaries of this technique, for which the therapist can use both hands like some kind of mechanical device. In clinical practice, massage is often applied in combination with other therapies such as exercise and other interventions, but also sometimes as a single treatment. A common way of using this technique is to combine the rules of physical medicine massage and neural therapy through acupuncture, where, without the insertion of the needle, but by using a specific instrument (vibrating) is achieved stimulation of acupuncture point superficial. Moreover, within the classical techniques of massage effleurage should be discarded, friction, kneading or pettrissage. If we make an analysis of the evidence of this technique as a routine therapeutic practice can see how there is limited evidence that massage gets the same effects as spinal manipulation and the use of the corset. More effective than spinal manipulation, exercise therapy and postural education, relaxation therapy, physical therapy and acupuncture are less effective than the use of therapeutic physical exercise combined with health education when discussing the effect upon the

improvement is greater in spinal manipulation75-78.

available to treat their musculoskeletal complaints.

symptoms of people suffering from chronic LBP.

back pain73, 79-83.

**4.1 Massage** 

**3.5 Clinical evidence of therapeutic exercise in physiotherapy** 

**4. Manual therapy as an intervention on chronic low back pain** 

effectiveness of using this therapy compared with placebo treatment in low back pain, although there is limited evidence about the similarity of effects caused by lumbar traction, massage and interferential therapy in chronic low back pain59,60.


#### **3.4 Clinical evidence of manual therapy in physiotherapy**

 Manipulation / mobilization, manual therapy techniques used in the short or long levers to move back. This move pushes the spinal joint beyond its range of motion, by a pulse of high velocity low amplitude. Those made with large amplitude, low velocity and passive movements often remain within the joint range.

With moderate evidence, one might argue that the mobilization of the spine gets better results in the treatment of low back pain a simulated mobilization, but get the same effect as standard medical practice through the use of analgesics.

The level of evidence becomes moderate when mobilization and standard medical practice are combined and is more effective than medical treatment in isolation. Evidence is also moderate when viewed equal effects produced by therapeutic exercise and manipulation in low back pain73,74.

 Massage: Soft tissue manipulation with the hands or a mechanical device through a variety of specific methods. As evidence, it seems that there is limited evidence when talking about the fact that massage causes on subjects suffering chronic back pain by saying that there is no difference between this technique and the use of a corset, that massage is more effective in symptomatological treatment of low back pain when compared to acupuncture, physical therapy, self-management education, the placebo treatment, postural education, relaxation therapy. There are also limited evidence that massage is as effective as manipulation in low back pain but, however, functional improvement is greater in spinal manipulation75-78.

#### **3.5 Clinical evidence of therapeutic exercise in physiotherapy**

As for the therapeutic exercise, there is moderate evidence that short-term improvements achieved over the reduction of pain and disability than passive treatments. There is strong evidence that treatment with therapeutic exercise is more effective than standard medical practice for both the reduction of pain, disability and the average time to return to work. This level of evidence is maintained when you try to say that strength training conditioning, there are more effective than other exercises in the treatment of chronic low back pain73, 79-83.

#### **4. Manual therapy as an intervention on chronic low back pain**

#### **4.1 Massage**

178 Low Back Pain

 Laser therapy: surface application of laser wavelength of 632-904 nm. Optimal treatment parameters (wavelength, dose, dose intensity) are uncertain. When analyzing the effect of this therapy as a means of reducing low back pain there is conflicting

 Lumbar support, brace or corset used to give passive support to the back. This type of instrument lacks scientific evidence when compared with placebo treatment or other

 Shortwave diathermy: Therapeutic elevation of the temperature of deep tissues by application of short wave electromagnetic radiation with a frequency range between 10 and 100 MHz This intervention methodology lacks scientific evidence when compared

 Traction: pulling intervention that aims to stretch the lumbar spine. ExSite a variety of methods can be used with this technique, but usually involve the use of a harness around the lower rib cage and revolves around the iliac crest, using free weights and pulleys, a motorized mechanism, inverse techniques or headband to cause traction. As evidence of this methodology of intervention, it is limited to say that lumbar traction is not more effective than sham traction and zero when compared with other methods of

 Transcutaneous electrical nerve stimulation (TENS) using surface electrodes, using electrical impulses seeking to relieve symptoms by changing the perception of pain. The evidence that this methodology is no better than placebo treatment of low back pain is strong, being moderate when compared to the electro-axial decompression, or

 Manipulation / mobilization, manual therapy techniques used in the short or long levers to move back. This move pushes the spinal joint beyond its range of motion, by a pulse of high velocity low amplitude. Those made with large amplitude, low velocity

With moderate evidence, one might argue that the mobilization of the spine gets better results in the treatment of low back pain a simulated mobilization, but get the same effect as

The level of evidence becomes moderate when mobilization and standard medical practice are combined and is more effective than medical treatment in isolation. Evidence is also moderate when viewed equal effects produced by therapeutic exercise and manipulation in

with a placebo or other treatment as a means of intervention in low back pain65. Therapeutic ultrasound: Therapeutic application of high frequency sound waves up to 3 MHz evidence that this technique is limited in treating back pain when compared to

placebo and no treatment when considering other methods of intervention66. Thermotherapy: superficial heat in the lower back. There is a lack of scientific evidence of this methodology when compared to placebo treatment or other treatment as an

traction, massage and interferential therapy in chronic low back pain59,60.

evidence about it61,62.

treatments for low back pain intervention63,64.

instrument of intervention on chronic low back pain66,67.

**3.4 Clinical evidence of manual therapy in physiotherapy** 

standard medical practice through the use of analgesics.

and passive movements often remain within the joint range.

intervention in low back pain67,68.

acupuncture66,69-72.

low back pain73,74.

effectiveness of using this therapy compared with placebo treatment in low back pain, although there is limited evidence about the similarity of effects caused by lumbar

> Massage is the technique used for longer physical therapists in history. Instinctive mode makes use has been used by almost every culture in history, like the Greeks and Romans (where, among other uses, was used to retrieve the athletes and gladiators, respectively, after the shows), the ancient Egypt, where priests were using it in conjunction with other therapeutic techniques and even in China, where emperors of the best massage therapists available to treat their musculoskeletal complaints.

> Although massage is socially understood as a technique of intervention whose focus is the muscle, it must have a broader definition because it is the set of soft tissues the main beneficiaries of this technique, for which the therapist can use both hands like some kind of mechanical device. In clinical practice, massage is often applied in combination with other therapies such as exercise and other interventions, but also sometimes as a single treatment.

> A common way of using this technique is to combine the rules of physical medicine massage and neural therapy through acupuncture, where, without the insertion of the needle, but by using a specific instrument (vibrating) is achieved stimulation of acupuncture point superficial. Moreover, within the classical techniques of massage effleurage should be discarded, friction, kneading or pettrissage. If we make an analysis of the evidence of this technique as a routine therapeutic practice can see how there is limited evidence that massage gets the same effects as spinal manipulation and the use of the corset. More effective than spinal manipulation, exercise therapy and postural education, relaxation therapy, physical therapy and acupuncture are less effective than the use of therapeutic physical exercise combined with health education when discussing the effect upon the symptoms of people suffering from chronic LBP.

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 181

Chronic low back pain, as defined previously, back pain is defined as pain and discomfort, located between the costal margin and the inferior gluteal folds, with or without referred pain from the leg. Chronic back pain defined as pain in this location for at least 12 weeks. This means we try to chronic sub-acute pain maintained for periods longer than 12 weeks or

Therapeutic physical exercise (TFE), can be defined as any program in which, during the sessions participants are required to perform static or dynamic movements and where the exercises were intended as a treatment for chronic low back pain, with supervised exercise

Being a chronic musculoskeletal disorder, therapeutic exercise, seems to be a good treatment option, however, some doubt is normal in this type of assault interventions such as exercise intensity, number of sessions per week, if you get the same effects regardless of the environment where the intervention takes place or whether the intervention should be

So far has always been measuring the use of physical activity account for these two variables independently, however, for several years, a new concept is gaining prominence when speaking of exercise weekly. This idea comes from the fusion of both and has an own unit of measurement, METs (metabolics equivalents). One MET is equivalent to the expenditure of an individual who sits for a minute. Thus, an adult walks One MET Represents an individual's energy while sitting quietly Expenditure per minute. An adult walking at 4.82 km / h in flat terrain and hard consumes about 3.3 METs, whereas if the speed go up to 8.05, also spending would amount to 8 METs or so. As the end of a week, accumulating energy expenditure a person will be the summation of everything he has accomplished during that

The concept of dose is often used to describe physical activity, but can be interpreted in many ways (cumulative, intensity, frequency, duration, physical activity ...). This idea gradually being introduced into clinical practice of a physical therapist to intervene on patients with chronic musculoskeletal disorders such as back pain, yet there is not much literature that has used this form of measurement in the low back pain. However, if there are some published studies comparing the optimal frequency of intervention on these patients through exercise. Thus there is strong evidence that all those interventions that make a subject and at the end of the week it has accumulated a minimum of two hours of treatment and a maximum of two hours and forty-five minutes of treatment on this type of

The physical factor is a priori, the most influential within the therapeutic effects of EFT as, individually planned and ensuring consistency in the precocity, the training effect will

group or individual. In any of these questions we will try to answer in this section.

**5.2 Exercise intensity and cumulative exercise: Number of weekly sessions** 

time period, being able to make an estimate of cumulative effort by the patient86.

**5. Active treatment in chronic low back pain: Exercise therapy** 

the appellants, where the current episode lasts at least this time.

**5.1 introduction** 

and / or prescribed.

pathology86-88.

**5.3 Individual or group exercise?** 

#### **4.2 Spinal manipulation / mobilization**

It is important to distinguish between what is manipulation and mobilization. Manipulation of the column is defined as an impulse of high velocity low amplitude that exceeds the limited range of motion but always runs within the anatomical limits of the joint. However, mobilization is understood as a low speed drive range of movement and manipulation, although in both cases remains the rule of not exceeding the anatomical limit of the joint.

Although the distinction between both methodologies, most studies that have been consulted didn`t made a clear distinction between each technique, but usually defined as "spinal manipulation package."

While these manual techniques are widely used as a tool in daily clinical practice, there are no randomized trials that allow too many draw firm conclusions about the effect that spinal manipulation leads.

While these manual techniques are widely used as a tool in daily clinical practice, there are no randomized trials that allow too many draw firm conclusions about the effect that spinal manipulation leads. Still, in recent years some trials have been developed that have allowed the increased strength of the conclusions, as they have increased the intrinsic quality of it and thereby allowing some light to the effect that these techniques lead to people with chronic LBP.

As for the evidence can be provided on the effect of manual therapy can bring to their use in the treatment of LBP symptomatological chronic, there are two limits that must be considered when interpreting the same. The first is that all interventions that have been observed allowing an evolution of the effects of manipulaición / mobilization in the short term, however, be important to determine how this technique can provide after long term intervention protocols, especially in this type of patients. On the other hand, there is also a problem regarding the unification of criteria in the different streams of existing manual therapy (manual medicine, osteopathy, physiotherapy, chiropractic ...) when defining a person qualified to perform such maneuvers. Based on these two aspects and based on the studies consulted, one could argue based on moderate evidence that manipulation / mobilization achieves better effects on symptoms of back pain than placebo treatment. Similarly, manipulation / mobilization used as a complement to standard medical treatment manage to increase the effect of this short term. On the other hand, it has found the same effects in the treatment of chronic low back pain when a therapist uses spinal manipulation when using a therapeutic exercise program, a program of back school or when compared with standard medical practice, although in the latter case, the evidence is strong rather than moderate 35,36,84,85.

Thus it's possible to see how the manipulation / mobilization vertebral have an effect simimar that could be seen in other health interventions in the treatment of chronic low back pain symptomatological. However, one of the aspects which would need to answer is to identify, within the range of possibilities that have qualified physical therapist to intervene, using manipulation / mobilization, subjects suffering from chronic back pain, what exercises are most effective in treatment of this disease, since there is no criterion when identifying them, the term is too imprecise.

#### **5. Active treatment in chronic low back pain: Exercise therapy**

#### **5.1 introduction**

180 Low Back Pain

It is important to distinguish between what is manipulation and mobilization. Manipulation of the column is defined as an impulse of high velocity low amplitude that exceeds the limited range of motion but always runs within the anatomical limits of the joint. However, mobilization is understood as a low speed drive range of movement and manipulation, although in both cases remains the rule of not exceeding the anatomical limit of the joint.

Although the distinction between both methodologies, most studies that have been consulted didn`t made a clear distinction between each technique, but usually defined as

While these manual techniques are widely used as a tool in daily clinical practice, there are no randomized trials that allow too many draw firm conclusions about the effect that spinal

While these manual techniques are widely used as a tool in daily clinical practice, there are no randomized trials that allow too many draw firm conclusions about the effect that spinal manipulation leads. Still, in recent years some trials have been developed that have allowed the increased strength of the conclusions, as they have increased the intrinsic quality of it and thereby allowing some light to the effect that these techniques lead to people with

As for the evidence can be provided on the effect of manual therapy can bring to their use in the treatment of LBP symptomatological chronic, there are two limits that must be considered when interpreting the same. The first is that all interventions that have been observed allowing an evolution of the effects of manipulaición / mobilization in the short term, however, be important to determine how this technique can provide after long term intervention protocols, especially in this type of patients. On the other hand, there is also a problem regarding the unification of criteria in the different streams of existing manual therapy (manual medicine, osteopathy, physiotherapy, chiropractic ...) when defining a person qualified to perform such maneuvers. Based on these two aspects and based on the studies consulted, one could argue based on moderate evidence that manipulation / mobilization achieves better effects on symptoms of back pain than placebo treatment. Similarly, manipulation / mobilization used as a complement to standard medical treatment manage to increase the effect of this short term. On the other hand, it has found the same effects in the treatment of chronic low back pain when a therapist uses spinal manipulation when using a therapeutic exercise program, a program of back school or when compared with standard medical practice, although in the latter case, the evidence is strong rather than

Thus it's possible to see how the manipulation / mobilization vertebral have an effect simimar that could be seen in other health interventions in the treatment of chronic low back pain symptomatological. However, one of the aspects which would need to answer is to identify, within the range of possibilities that have qualified physical therapist to intervene, using manipulation / mobilization, subjects suffering from chronic back pain, what exercises are most effective in treatment of this disease, since there is no criterion when

**4.2 Spinal manipulation / mobilization** 

"spinal manipulation package."

manipulation leads.

chronic LBP.

moderate 35,36,84,85.

identifying them, the term is too imprecise.

Chronic low back pain, as defined previously, back pain is defined as pain and discomfort, located between the costal margin and the inferior gluteal folds, with or without referred pain from the leg. Chronic back pain defined as pain in this location for at least 12 weeks. This means we try to chronic sub-acute pain maintained for periods longer than 12 weeks or the appellants, where the current episode lasts at least this time.

Therapeutic physical exercise (TFE), can be defined as any program in which, during the sessions participants are required to perform static or dynamic movements and where the exercises were intended as a treatment for chronic low back pain, with supervised exercise and / or prescribed.

Being a chronic musculoskeletal disorder, therapeutic exercise, seems to be a good treatment option, however, some doubt is normal in this type of assault interventions such as exercise intensity, number of sessions per week, if you get the same effects regardless of the environment where the intervention takes place or whether the intervention should be group or individual. In any of these questions we will try to answer in this section.

#### **5.2 Exercise intensity and cumulative exercise: Number of weekly sessions**

So far has always been measuring the use of physical activity account for these two variables independently, however, for several years, a new concept is gaining prominence when speaking of exercise weekly. This idea comes from the fusion of both and has an own unit of measurement, METs (metabolics equivalents). One MET is equivalent to the expenditure of an individual who sits for a minute. Thus, an adult walks One MET Represents an individual's energy while sitting quietly Expenditure per minute. An adult walking at 4.82 km / h in flat terrain and hard consumes about 3.3 METs, whereas if the speed go up to 8.05, also spending would amount to 8 METs or so. As the end of a week, accumulating energy expenditure a person will be the summation of everything he has accomplished during that time period, being able to make an estimate of cumulative effort by the patient86.

The concept of dose is often used to describe physical activity, but can be interpreted in many ways (cumulative, intensity, frequency, duration, physical activity ...). This idea gradually being introduced into clinical practice of a physical therapist to intervene on patients with chronic musculoskeletal disorders such as back pain, yet there is not much literature that has used this form of measurement in the low back pain. However, if there are some published studies comparing the optimal frequency of intervention on these patients through exercise. Thus there is strong evidence that all those interventions that make a subject and at the end of the week it has accumulated a minimum of two hours of treatment and a maximum of two hours and forty-five minutes of treatment on this type of pathology86-88.

#### **5.3 Individual or group exercise?**

The physical factor is a priori, the most influential within the therapeutic effects of EFT as, individually planned and ensuring consistency in the precocity, the training effect will

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 183

with a limited level of evidence has been found that intensive multidisciplinary programs face can not be said which of these is most effective. Furthermore, while maintaining that level of evidence, differences were no differences between aerobic and strength exercises, in terms of pain and the degree of long-term disability, no differences between the effects on the reduction pain, to perform the exercise in just 4 sessions, compared to 8 sessions, aerobic exercises are superior to lumbar flexion, in terms of pain immediately after the program and

a program for individualized home exercise is more effective than general exercises.

**health education** 

time and form.

limit.

in the patient.

**6.1 What is the brief advice** 

by helping the integration of the pathology of the patient.

determinants of credibility and effectiveness of the intervention.

**6. General supplement to chronic low back pain treatment: Brief advice and** 

When talking about brief advice, it is difficult to define this definition in terms of content,

From a temporal point of view, there are two types of interventions that target different. One aims to ease concerns, worries and doubts that early intervention would address the initial short questions and fears that the patient suffers. On the other hand, there are some interventions that are longer and requiring more profound impact on aspects of the problem

While there are different ways to provide brief advice to the patient (in person, by telephone, with a booklet written, using internet ...), has not been able to show which method is most effective when the patient integrate such training, although they can identify some problems that can affect certain methodologies, such as internet use, as in older people, who are not familiar with the use of this medium can be an insurmountable

We are talking about a process in which a person gives to another or other information about a specific problem, chronic low back pain. Here's beliefs, the communication skills by the physiotherapist, the material available are some aspects that could influence the

On the other hand, it would be important to consider those who have a paid position and it is absent due to any pressure that they may suffer by changing their employment status is experiencing, it would be important to monitor absenteeism labor is causing low back pain

So it appears that brief advice delivered by a physiotherapist or clinical staff is a promising tool that can help save significant time and resources which can benefit both the patient and the clinician. This statement could be shot by studies that demonstrate strong evidence that brief advice is as effective as aerobic exercise routine or physical therapy in reducing disability, shortening time to return to work or patient's daily activities. Furthermore, with moderate evidence, we can say that brief advice is more effective than usual care in reducing the time of return to employment and the promotion of self-care helps reduce the typical symptoms of lumbar pain as pain or disability. However, there is limited evidence that the transmission of information through internet use is more effective than no intervention in reducing pain or disability of a person who suffers chronic back pain94-98.

achieve the objectives previously established. Therefore, the key lies in the design of achievable objectives for each condition and adapted to the evolutionary process.

Thus, based on the objective pursued by each patient, we can differentiate between: planning treatment for recovery training, when we try to restore or improve impaired function, and therapeutic planning training for compensation, when we try to compensate or improve global function, because the current problem is not improved.

On the other hand, and understanding that an EFT program conducted as a means of intervention on chronic low back pain means that the duration of such treatment is usually not less than two months, so that, taking into account the cost of a physiotherapist for each hour of work, would be difficult for all patients who suffer from chronic back pain, could make an intervention where the therapist-patient ratio was 1:1. Thus, a way to save the expense would increase this ratio to reach heights that range between 1:8 and 1:12.

For its part, the therapist could make an identification of the active treatment of the person based on this initial assessment. Thus, tracking group, but a search of the objectives individually get very interesting balance between the cost of services received by the patient and increasing symptomatic improvement by the patient89,90.

#### **5.4 Environment where the exercise should be performed: Is the water always a good option?**

More and more frequent the facilities they offer services that can be performed physiotherapy intervention for chronic musculoskeletal disorders in the aquatic environment, partially or completely carried out within it. Conducting the activity in the water, has a number of advantages such as decompression of the lumbar spine validated with accurate measurements of body height, changes in all functional parameters of mobility, strength and endurance as well as improved cardio-metabolic disorders negatively and significantly correlated with the degree of pain and disability and provide for adequate monitoring and follow-up after individual assessment through indicators with heart rate and subjective scales of effort. However, it also presents some limitations, especially in deep pools, such as feelings of insecurity in those who are not fluent in the aquatic environment.

It found, however, studies show that exercise performed in water treatment is more effective than EFT made out of it or vice versa, so it will be a patient choice and / or choosing a therapist use a certain methodology or another.

However, if you have found in clinical trials has been shown that the same treatment carried out of water but with water running supplementation produces better results in symptomatic improvement in patients with chronic LBP91,-93.

In conclusion of this section and articles based on the respondents, one could say with strong evidence that strengthening exercises are more effective than other types of exercises. Likewise, and maintaining this level of evidence has shown that exercise is more effective than general medical practice to reduce pain, disability, and return to work in the medium term (3-6 months), but not is more effective than conventional physical therapy intervention.

The level of evidence when it comes down to that moderate exercise is more effective than passive treatment in reducing pain and / or disability1,3,35,73. On the other hand, and already with a limited level of evidence has been found that intensive multidisciplinary programs face can not be said which of these is most effective. Furthermore, while maintaining that level of evidence, differences were no differences between aerobic and strength exercises, in terms of pain and the degree of long-term disability, no differences between the effects on the reduction pain, to perform the exercise in just 4 sessions, compared to 8 sessions, aerobic exercises are superior to lumbar flexion, in terms of pain immediately after the program and a program for individualized home exercise is more effective than general exercises.

#### **6. General supplement to chronic low back pain treatment: Brief advice and health education**

#### **6.1 What is the brief advice**

182 Low Back Pain

achieve the objectives previously established. Therefore, the key lies in the design of

Thus, based on the objective pursued by each patient, we can differentiate between: planning treatment for recovery training, when we try to restore or improve impaired function, and therapeutic planning training for compensation, when we try to compensate

On the other hand, and understanding that an EFT program conducted as a means of intervention on chronic low back pain means that the duration of such treatment is usually not less than two months, so that, taking into account the cost of a physiotherapist for each hour of work, would be difficult for all patients who suffer from chronic back pain, could make an intervention where the therapist-patient ratio was 1:1. Thus, a way to save the

For its part, the therapist could make an identification of the active treatment of the person based on this initial assessment. Thus, tracking group, but a search of the objectives individually get very interesting balance between the cost of services received by the patient

**5.4 Environment where the exercise should be performed: Is the water always a good** 

More and more frequent the facilities they offer services that can be performed physiotherapy intervention for chronic musculoskeletal disorders in the aquatic environment, partially or completely carried out within it. Conducting the activity in the water, has a number of advantages such as decompression of the lumbar spine validated with accurate measurements of body height, changes in all functional parameters of mobility, strength and endurance as well as improved cardio-metabolic disorders negatively and significantly correlated with the degree of pain and disability and provide for adequate monitoring and follow-up after individual assessment through indicators with heart rate and subjective scales of effort. However, it also presents some limitations, especially in deep pools, such as feelings of insecurity in those who are not fluent in the aquatic environment. It found, however, studies show that exercise performed in water treatment is more effective than EFT made out of it or vice versa, so it will be a patient choice and / or choosing a

However, if you have found in clinical trials has been shown that the same treatment carried out of water but with water running supplementation produces better results in

In conclusion of this section and articles based on the respondents, one could say with strong evidence that strengthening exercises are more effective than other types of exercises. Likewise, and maintaining this level of evidence has shown that exercise is more effective than general medical practice to reduce pain, disability, and return to work in the medium term (3-6 months), but not is more effective than conventional physical therapy intervention. The level of evidence when it comes down to that moderate exercise is more effective than passive treatment in reducing pain and / or disability1,3,35,73. On the other hand, and already

achievable objectives for each condition and adapted to the evolutionary process.

expense would increase this ratio to reach heights that range between 1:8 and 1:12.

or improve global function, because the current problem is not improved.

and increasing symptomatic improvement by the patient89,90.

therapist use a certain methodology or another.

symptomatic improvement in patients with chronic LBP91,-93.

**option?** 

When talking about brief advice, it is difficult to define this definition in terms of content, time and form.

From a temporal point of view, there are two types of interventions that target different. One aims to ease concerns, worries and doubts that early intervention would address the initial short questions and fears that the patient suffers. On the other hand, there are some interventions that are longer and requiring more profound impact on aspects of the problem by helping the integration of the pathology of the patient.

While there are different ways to provide brief advice to the patient (in person, by telephone, with a booklet written, using internet ...), has not been able to show which method is most effective when the patient integrate such training, although they can identify some problems that can affect certain methodologies, such as internet use, as in older people, who are not familiar with the use of this medium can be an insurmountable limit.

We are talking about a process in which a person gives to another or other information about a specific problem, chronic low back pain. Here's beliefs, the communication skills by the physiotherapist, the material available are some aspects that could influence the determinants of credibility and effectiveness of the intervention.

On the other hand, it would be important to consider those who have a paid position and it is absent due to any pressure that they may suffer by changing their employment status is experiencing, it would be important to monitor absenteeism labor is causing low back pain in the patient.

So it appears that brief advice delivered by a physiotherapist or clinical staff is a promising tool that can help save significant time and resources which can benefit both the patient and the clinician. This statement could be shot by studies that demonstrate strong evidence that brief advice is as effective as aerobic exercise routine or physical therapy in reducing disability, shortening time to return to work or patient's daily activities. Furthermore, with moderate evidence, we can say that brief advice is more effective than usual care in reducing the time of return to employment and the promotion of self-care helps reduce the typical symptoms of lumbar pain as pain or disability. However, there is limited evidence that the transmission of information through internet use is more effective than no intervention in reducing pain or disability of a person who suffers chronic back pain94-98.

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 185

The current concept of man does that is defined beyond its own anatomic barrier. Your life will be determined by biological, psychological and social. The response and adaptation to each individual contribution they will determine your state of health. Thus, the therapeutic approach should contain different proportions depending on the case, a portion of each of

The content of multidisciplinary treatment programs usually consists of a broad mix of the physical, social and behavioral modification and drug use. Usually, these programs are held for a considerable number of hours a week, sometimes even on an inpatient basis. The content of these programs and how they are labeled or described is very variable. For example, multidisciplinary biopsychosocial rehabilitation, rehabilitation programs, behavioral programs, back schools, or functional restoration programs (FR) may involve one or more of these components. True multidisciplinary treatment program that includes medical (drug treatment, education), physical (exercise), vocational and behavioral components must always be at least three health professionals with clinical backgrounds (doctor, physiotherapist, psychologist), although the intensity and content of

Based on the evidence we have seen in the preceding paragraphs, it appears that the most effective combination, a priori, would be to combine therapeutic exercise, manual therapy and health education and behavioral programs. Each one of which could be developed as



A priori one might tend to think that this question does not make much sense, because a multimodal program should be based on evidence offering a combination of those therapies that are most effective, ensuring a summation of effects, however, failed to show that as a result of a multimodal treatment intervention to obtain the sum of the effects of each of the interventions separately. It is very likely not the case because there may be variables that are improved with an intervention or another. It is also important to remember that physiotherapy intervention is aimed at symptomatic improvement of this alteration of the musculoskeletal system, and the patient support in assessing the patient's results will play

physiotherapist to encourage a return to normal activities.

**7. Multimodal treatment in chronic low back pain** 

**7.1 Introduction** 

these perspectives.

follows:

stabilization.

an important role.

**7.2 Combined or add effects** 

interdisciplinary therapy varies widely.

#### **6.2 Cognitive behavioral methods of treatment**

It is important to consider that treatment of low back pain is not solely focused on eliminating chronic underlying pathology, but the reduction in symptoms and disability that it causes by changing the contingencies that the environment of the patient may have and through cognitive processes. Of these, the cognitive processes can be divided into three different styles of intervention depending on the therapeutic approach is desired to give. This may be operant, cognitive and respondent. Each of them focuses on the modification of one of the three response systems that characterize emotional experiences that are the behavior, cognitions and physiological reactivity.

The first is based on the principles of operant conditioning of Skinner (1953)99, where healthy behaviors are reinforced positively and to all those aspects that relate to negative symptoms like pain, is stripped of patient care. The assistance of the people around them as partner, family, friends, have an important role in this process.

Cognitive therapy for its part has as its objective the identification and modification of the cognitive aspects of patients on pain and disability. This change in the definition of pain or expectations of control over it is achieved with cognitive restructuring techniques (directly) or by changing beliefs, feelings and thoughts100.

Finally, the defendant treatment which aims to achieve is a change in the direct physiological response, such as by muscle relaxation, for which the patient seeks to provide a model of relationship between stress and pain, teaching himself to use the relaxation in response to accumulated muscle tension. To achieve this, it uses material that may help the patient understand what is happening, such as biofeedback or EMG.

As you can see, these methods seek to cognitive and behavioral changes in both behavior and cognition on the basis of treatment being offered. The main approach used by these techniques is that both pain and disability that this condition creates are the result of psychological and social factors, not just because of a somatic pathology.

Although they appear several objectives and methodologies used by cognitive and behavioral therapies, these two techniques have several things in common:


Different studies have demonstrated the effectiveness of behavioral treatment in chronic low back pain. Thus, one could argue with strong evidence that this intervention is more effective than no treatment or placebo. On the other hand, always with the same level of evidence, we can say that there are no differences in results obtained with the three streams of treatment. In addition, the behavioral approach is demonstrated more effective than traditional treatments in facilitating the return to work by patients.

The evidence comes down to moderation for that treatment to cognitive-behavioral treatment has joined other effects of long and medium term chronic low back pain. In addition, there is limited evidence that intervention on pain, disability, functional status, depression or therapeutic exercise and behavioral therapy are equally effective100-104.

### **7. Multimodal treatment in chronic low back pain**

#### **7.1 Introduction**

184 Low Back Pain

It is important to consider that treatment of low back pain is not solely focused on eliminating chronic underlying pathology, but the reduction in symptoms and disability that it causes by changing the contingencies that the environment of the patient may have and through cognitive processes. Of these, the cognitive processes can be divided into three different styles of intervention depending on the therapeutic approach is desired to give. This may be operant, cognitive and respondent. Each of them focuses on the modification of one of the three response systems that characterize emotional experiences that are the

The first is based on the principles of operant conditioning of Skinner (1953)99, where healthy behaviors are reinforced positively and to all those aspects that relate to negative symptoms like pain, is stripped of patient care. The assistance of the people around them as

Cognitive therapy for its part has as its objective the identification and modification of the cognitive aspects of patients on pain and disability. This change in the definition of pain or expectations of control over it is achieved with cognitive restructuring techniques (directly)

Finally, the defendant treatment which aims to achieve is a change in the direct physiological response, such as by muscle relaxation, for which the patient seeks to provide a model of relationship between stress and pain, teaching himself to use the relaxation in response to accumulated muscle tension. To achieve this, it uses material that may help the

As you can see, these methods seek to cognitive and behavioral changes in both behavior and cognition on the basis of treatment being offered. The main approach used by these techniques is that both pain and disability that this condition creates are the result of

Although they appear several objectives and methodologies used by cognitive and

To get a change maladaptive thoughts, feelings and behaviors, you can make use of

Different studies have demonstrated the effectiveness of behavioral treatment in chronic low back pain. Thus, one could argue with strong evidence that this intervention is more effective than no treatment or placebo. On the other hand, always with the same level of evidence, we can say that there are no differences in results obtained with the three streams of treatment. In addition, the behavioral approach is demonstrated more effective than

The evidence comes down to moderation for that treatment to cognitive-behavioral treatment has joined other effects of long and medium term chronic low back pain. In addition, there is limited evidence that intervention on pain, disability, functional status,

depression or therapeutic exercise and behavioral therapy are equally effective100-104.

**6.2 Cognitive behavioral methods of treatment** 

behavior, cognitions and physiological reactivity.

or by changing beliefs, feelings and thoughts100.

partner, family, friends, have an important role in this process.

patient understand what is happening, such as biofeedback or EMG.

psychological and social factors, not just because of a somatic pathology.

behavioral therapies, these two techniques have several things in common:

The patient is able to acquire skills to solve various problems.

traditional treatments in facilitating the return to work by patients.

The behavior and emotions of individuals are influenced by your thoughts.

structured techniques to help identify, control and change these conditions.

The current concept of man does that is defined beyond its own anatomic barrier. Your life will be determined by biological, psychological and social. The response and adaptation to each individual contribution they will determine your state of health. Thus, the therapeutic approach should contain different proportions depending on the case, a portion of each of these perspectives.

The content of multidisciplinary treatment programs usually consists of a broad mix of the physical, social and behavioral modification and drug use. Usually, these programs are held for a considerable number of hours a week, sometimes even on an inpatient basis. The content of these programs and how they are labeled or described is very variable. For example, multidisciplinary biopsychosocial rehabilitation, rehabilitation programs, behavioral programs, back schools, or functional restoration programs (FR) may involve one or more of these components. True multidisciplinary treatment program that includes medical (drug treatment, education), physical (exercise), vocational and behavioral components must always be at least three health professionals with clinical backgrounds (doctor, physiotherapist, psychologist), although the intensity and content of interdisciplinary therapy varies widely.

Based on the evidence we have seen in the preceding paragraphs, it appears that the most effective combination, a priori, would be to combine therapeutic exercise, manual therapy and health education and behavioral programs. Each one of which could be developed as follows:


#### **7.2 Combined or add effects**

A priori one might tend to think that this question does not make much sense, because a multimodal program should be based on evidence offering a combination of those therapies that are most effective, ensuring a summation of effects, however, failed to show that as a result of a multimodal treatment intervention to obtain the sum of the effects of each of the interventions separately. It is very likely not the case because there may be variables that are improved with an intervention or another. It is also important to remember that physiotherapy intervention is aimed at symptomatic improvement of this alteration of the musculoskeletal system, and the patient support in assessing the patient's results will play an important role.

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 187

In turn, as has been observed in recent years have seen an expansion of treatment in chronic diseases múscuoloesqueléticas. Of these, the most common of all is the low back, creating groups and specific methods of treatment for this condition. Regardless of whether the agency offers these services is public or private, both seeking to increase efficiency and, therefore, a better balance between cost - effectiveness. This view could prompt more commercial thinking about seeking treatment depersonalization of economic performance just the same, however, studies which demonstrate the optimal frequency of low back pain intervention can help better use of space resources and temporary available, and may favor the increased supply and therefore the number of patients treated and satisfied with the

In recent years there have been several published studies that attempted to answer this question considering different variables as a criterion for differentiating lumbálgicos groups receiving treatment. The main subdivisions were made based on body mass index, based on the environment where treatment was performed at the age of people who

He has watched a speech delivered in groups where the criteria of subdivision was the body mass index113, evolved similar patients in different intervention groups, it seems that this variable does not affect to the evolution of the patient may suffer in terms of symptomatic improvement of low back pain. These results are contradictory to a study that is under review, according to which, people who are obese are not only more likely to suffer back pain, but the treatment effect is inversely proportional to the rate of mass body

On the other hand, it has been shown how optimizing available resources are two key aspects to be considered, the number of sessions per week and the medium in which the intervention. This has been shown how a person performing two sessions of physical therapy to improve symptoms of low back pain evolves faster than those who performed only one session per week87,114. However, among those who engaged in twice-weekly and three symptomatic evolution could be comparable. This could be in line with the show already in 2007 brought the American College of Sports Medicine from the recommendations of which does not speak of sessions a week, but a cumulative total exercise per week based on the intensity. In paragraph 5 is much deeper in this

Another aspect that has been taken into account when classifying interventions is one in which the environment is considered where the intervention. It has been observed how the subject performs a physical therapy intervention completely dry or a part of the exercise in the water, get a similar evolution in both media. This allows it to be the patient who chooses what kind of environment you prefer when making your own protocol for intervention. However, it has watched a physiotherapy intervention which will supplement water running protocol, the patient experiences an increase in symptom improvement when

service received.

perform it.

present.

argument.

**8.3 Evidence of increased effect: Studies published** 

performing this protocol with respect to when it does.

#### **7.3 Multimodal treatment: When you do when not**

From a health policy, to where it shifts the balance of costs and benefits, as these multimodal intervention programs can make a way out of health care resources. However, always committed and difficult to assign economic value to the quality of life, function, disability and / or pain, so to complete the analysis of cost-benefit can be tricky. On the other hand, would be included in this analysis are trials that can determine whether the effects on employment status, in terms of availability or fitness for patients who suffer from chronic back pain, in addition to a comparison of the response mode with the subjects on the basis of gender or age.

Although, as noted above, is necessary to deepen the results that can provide treatment multidisciplianar subjects suffering chronic back pain be stipulated that some evidence (strong and moderate) have been obtained in this regard. Thus, strong evidence, one could argue that a treatment that combines intense physical training and behavioral therapies integrated within the same treatment protocol, is able to reduce absenteeism in workers who suffer from chronic back pain. Likewise, one could say with strong evidence that those subjects who suffer chronic back pain have reduced pain and disability, improving the function by a multidisciplinary program of physiotherapy intervention105-112.

On the other hand, there is moderate evidence that intensive rehabilitative multidisciplinary program is more effective in reducing pain than non-multidisciplinary outpatient therapy or even the usual treatment.

#### **8. How to increase the effect of chronic low back pain treatment? Intervention in subgroups**

#### **8.1 Introduction**

When asked how to increase the effect of treatment in low back pain can be considered two types of responses. The first comes from an actual increase of the effect that treatment can bring to a particular type of patients, which would require the division of patients with low back pain whose treatment in specific subgroups specifically consideration of its characteristics making a proposed intervention much tighter to the subject in particular and the general group.

On the other side and to a very heterogeneous reality to which therapists have to face the world, another perspective that could provide a valid answer to this question would be to seek maximum efficiency of resources available to the professional clinician, not only referring to the material, but also time and space available.

#### **8.2 Different groups of variables divided to chronic low back pain**

If we consider each individual perspective, it could provide two different types of responses. The first was pursuing a net improvement of treatment effect, which would be necessary to clarify factors that define the person, such as age, sex, body mass index, and so on. chasing in a group intervention, a personalized treatment as closely as possible. Thus, the main factor in making the subgroups born of the characteristics of each subject.

From a health policy, to where it shifts the balance of costs and benefits, as these multimodal intervention programs can make a way out of health care resources. However, always committed and difficult to assign economic value to the quality of life, function, disability and / or pain, so to complete the analysis of cost-benefit can be tricky. On the other hand, would be included in this analysis are trials that can determine whether the effects on employment status, in terms of availability or fitness for patients who suffer from chronic back pain, in addition to a comparison of the response mode with the subjects on the basis of

Although, as noted above, is necessary to deepen the results that can provide treatment multidisciplianar subjects suffering chronic back pain be stipulated that some evidence (strong and moderate) have been obtained in this regard. Thus, strong evidence, one could argue that a treatment that combines intense physical training and behavioral therapies integrated within the same treatment protocol, is able to reduce absenteeism in workers who suffer from chronic back pain. Likewise, one could say with strong evidence that those subjects who suffer chronic back pain have reduced pain and disability, improving the

On the other hand, there is moderate evidence that intensive rehabilitative multidisciplinary program is more effective in reducing pain than non-multidisciplinary outpatient therapy or

When asked how to increase the effect of treatment in low back pain can be considered two types of responses. The first comes from an actual increase of the effect that treatment can bring to a particular type of patients, which would require the division of patients with low back pain whose treatment in specific subgroups specifically consideration of its characteristics making a proposed intervention much tighter to the subject in particular and

On the other side and to a very heterogeneous reality to which therapists have to face the world, another perspective that could provide a valid answer to this question would be to seek maximum efficiency of resources available to the professional clinician, not only

If we consider each individual perspective, it could provide two different types of responses. The first was pursuing a net improvement of treatment effect, which would be necessary to clarify factors that define the person, such as age, sex, body mass index, and so on. chasing in a group intervention, a personalized treatment as closely as possible. Thus,

the main factor in making the subgroups born of the characteristics of each subject.

function by a multidisciplinary program of physiotherapy intervention105-112.

**8. How to increase the effect of chronic low back pain treatment?** 

referring to the material, but also time and space available.

**8.2 Different groups of variables divided to chronic low back pain** 

**7.3 Multimodal treatment: When you do when not** 

gender or age.

even the usual treatment.

**8.1 Introduction** 

the general group.

**Intervention in subgroups** 

In turn, as has been observed in recent years have seen an expansion of treatment in chronic diseases múscuoloesqueléticas. Of these, the most common of all is the low back, creating groups and specific methods of treatment for this condition. Regardless of whether the agency offers these services is public or private, both seeking to increase efficiency and, therefore, a better balance between cost - effectiveness. This view could prompt more commercial thinking about seeking treatment depersonalization of economic performance just the same, however, studies which demonstrate the optimal frequency of low back pain intervention can help better use of space resources and temporary available, and may favor the increased supply and therefore the number of patients treated and satisfied with the service received.

#### **8.3 Evidence of increased effect: Studies published**

In recent years there have been several published studies that attempted to answer this question considering different variables as a criterion for differentiating lumbálgicos groups receiving treatment. The main subdivisions were made based on body mass index, based on the environment where treatment was performed at the age of people who perform it.

He has watched a speech delivered in groups where the criteria of subdivision was the body mass index113, evolved similar patients in different intervention groups, it seems that this variable does not affect to the evolution of the patient may suffer in terms of symptomatic improvement of low back pain. These results are contradictory to a study that is under review, according to which, people who are obese are not only more likely to suffer back pain, but the treatment effect is inversely proportional to the rate of mass body present.

On the other hand, it has been shown how optimizing available resources are two key aspects to be considered, the number of sessions per week and the medium in which the intervention. This has been shown how a person performing two sessions of physical therapy to improve symptoms of low back pain evolves faster than those who performed only one session per week87,114. However, among those who engaged in twice-weekly and three symptomatic evolution could be comparable. This could be in line with the show already in 2007 brought the American College of Sports Medicine from the recommendations of which does not speak of sessions a week, but a cumulative total exercise per week based on the intensity. In paragraph 5 is much deeper in this argument.

Another aspect that has been taken into account when classifying interventions is one in which the environment is considered where the intervention. It has been observed how the subject performs a physical therapy intervention completely dry or a part of the exercise in the water, get a similar evolution in both media. This allows it to be the patient who chooses what kind of environment you prefer when making your own protocol for intervention. However, it has watched a physiotherapy intervention which will supplement water running protocol, the patient experiences an increase in symptom improvement when performing this protocol with respect to when it does.

Physiotherapy Treatment on Chronic Non Specific Low Back Pain 189

Paracetamol < mefenemic acid Paracetamol = NSAIDs NSAIDs > Placebo

NSAIDs = Muscle relaxants NSAIDs = opioid analgesics NSAIDS > non-drug treatments Muscle relaxants > Placebo Spinal Mobilization > Placebo

Spinal Mobilization = Analgesic

TE > Brief. Ed. Interv. Prom. SelfC Flexion Exercise > Extension Exercise

Multidisciplinary Treatment > GP Behavioral Treatment > GP

Back School = Physical Therapy Back School < General Exercise Brief. Ed. Interv. Prom. SelfC > GP Back School = McKenzie exercises

Paracetamol = Aspirin Bed rest < Placebo

Remain Active > Bed Rest

Paracetamol= indomethacin Spinal Manipulation > Massage

Exercise

TE > Placebo TE > Bed Rest

TE > Massage

Spinal Mobilization = Therapeutic

Chronic NLBP Acute NLBP

Brief. Ed. Interv. Prom. SelfC. = Aerobic Exerc.

Brief educational interventions to promote

Therapeutic Exercise = Gnarl Physiotherapy.

self-care. = Usual physiotherapy.

Brief. Ed. Interv. Prom. SelfC. = GP.

Back School = Brief. Ed. Interv. Prom. SelfC

Back School = Manual Therapy.

MT = Usual physiotherapy.

TE > Passive Interventions

Laser therapy ≠ Placebo Ultrasound ≠ Placebo Massage > Placebo Massage > Acupuncture Massage > Relax therapy

TE ≠ Multidisciplinary program Aerobic Exercise > Flexion exercise

Individual Exercise. > Generic exercise Aerobic Exercise = Strength Exercise

Table 2. Low back pain evidence after revision

LEVEL A LEVEL B LEVEL C LEVEL D

TENS=Placebo

MT = GP

TE = Other Exercise TE > General Practice

Back School = Exercise

MT > Placebo MT

MT = Back School

MT + GP > GP

Massage = MT

Diathermia = Placebo

2 = 4 Weekly sessions

Interferential = Placebo


Table 1. Appropriateness of treatment based on pathology

Interferential therapy X X X Laser therapy X X X Lumbar supports X X X Shortwave diathermy X X X Therapeutic ultrasound X X X Thermotherapy X X X Traction X X X

Exercise therapy X √ √ Bed rest X √ √ Active lifestile √ √ √

Manipulation/mobilisation √ √ √

Massage X X X

Back schools X √ √

interventions to promote self-care <sup>√</sup> <sup>√</sup> <sup>√</sup>

methods <sup>√</sup> <sup>√</sup> <sup>√</sup> Multidisciplinary treatment X √ √ Antidepressants √ √ √ Muscle relaxants √ √ √ NSAIDs √ √ √ Capsaicin √ √ √ Paracetamol √ √ √ Epidural steroids X X X

Acupuncture X X X Neuroreflexotherapy √ √

Table 1. Appropriateness of treatment based on pathology

ACUTE LBP SUB-ACUTE

X X X

√ √

LBP CHRONIC LBP

TREATMENT

PHYSICAL THERAPY

Manual therapy

Transcutaneous electrical

nerve stimulation

Minimal contact/brief educational

Cognitive-behavioural treatment

Percutaneous electrical nerve

stimulation (PENS)

(TENS)


Table 2. Low back pain evidence after revision

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**9** 

*USA* 

Marcia Miller Spoto *Nazareth College of Rochester,* 

**Conservative Management of Low Back Pain** 

Low back pain is a common human experience. Especially in developed countries, low back pain has become a health condition with significant socio-economic implications. The costs of treating back and neck pain disorders in the US have increased substantially over the past 15-20 years, with the majority of these costs attributed to relatively invasive medical procedure such as injections and surgery. Despite the increased cost, there does not appear to be a corresponding improvement in function among individuals reporting spine pain over this same time period, nor improved general health outcomes (Martin BI et al, 2008). Back pain is a symptom and not a specific health condition or disease. There are many musculoskeletal and non-musculoskeletal causes of low back pain. Health care providers who treat back pain must engage in differential diagnosis as a first step in addressing a person with a back complaint. When back symptoms are caused by visceral or systemic disease, the patient must be referred to an appropriate medical specialist. Similarly, when back symptoms are caused by serious musculoskeletal pathology, the clinician should refer the patient appropriately. There conditions involving pathophysiologic changes in the lumbosacral spine, however, which can be successfully managed with more conservative approaches to care (Weinstein JN et al, 2006). Importantly, in many cases back pain can be considered *non-specific* and unrelated to pathologic change (Savage RA et al, 1997). Movement impairments can underlie both pathoanatomic and non-pathoanatomic causes of low back pain and these impairments are often the focus of conservative management

Beyond the first step of differential diagnosis, the major challenge for health care professionals involved in the treatment of back pain is diagnosing the problem in ways that will direct appropriate treatment and establish a more accurate prognosis. The International Classification of Disease (ICD) system (World Health Organization, 2005), which is universally accepted as a classification system for health conditions, has not been found to be particularly helpful from a prognostic standpoint or in directing interventions for back pain (Riddle DL, 1998). One of the reasons for this is that there is often a weak relationship between pathologic changes noted on imaging and an individual's level of symptomotolgy or function (Boos N et al, 200). Another reason is that again, by far, the majority of cases of low back pain can be considered non-specific and are not attributable to serious underlying

pathology. So there is a need for new models of diagnosis that are more meaningful.

One of the themes of this chapter is that the diagnostic process is central to the overall management of back pain. It is a pivotal point around which clinical decisions are rendered.

**1. Introduction** 

(Sahrmann SA, 2002).

[114] Sato D, Kaneda K, Wakabayashi H, Nomura T. The water exercise improves healthrelated quality of life of frail elderly people at day service facility. Qual Life Res. 2007;16;1577-85.

### **Conservative Management of Low Back Pain**

#### Marcia Miller Spoto

*Nazareth College of Rochester, USA* 

#### **1. Introduction**

198 Low Back Pain

[114] Sato D, Kaneda K, Wakabayashi H, Nomura T. The water exercise improves health-

2007;16;1577-85.

related quality of life of frail elderly people at day service facility. Qual Life Res.

Low back pain is a common human experience. Especially in developed countries, low back pain has become a health condition with significant socio-economic implications. The costs of treating back and neck pain disorders in the US have increased substantially over the past 15-20 years, with the majority of these costs attributed to relatively invasive medical procedure such as injections and surgery. Despite the increased cost, there does not appear to be a corresponding improvement in function among individuals reporting spine pain over this same time period, nor improved general health outcomes (Martin BI et al, 2008).

Back pain is a symptom and not a specific health condition or disease. There are many musculoskeletal and non-musculoskeletal causes of low back pain. Health care providers who treat back pain must engage in differential diagnosis as a first step in addressing a person with a back complaint. When back symptoms are caused by visceral or systemic disease, the patient must be referred to an appropriate medical specialist. Similarly, when back symptoms are caused by serious musculoskeletal pathology, the clinician should refer the patient appropriately. There conditions involving pathophysiologic changes in the lumbosacral spine, however, which can be successfully managed with more conservative approaches to care (Weinstein JN et al, 2006). Importantly, in many cases back pain can be considered *non-specific* and unrelated to pathologic change (Savage RA et al, 1997). Movement impairments can underlie both pathoanatomic and non-pathoanatomic causes of low back pain and these impairments are often the focus of conservative management (Sahrmann SA, 2002).

Beyond the first step of differential diagnosis, the major challenge for health care professionals involved in the treatment of back pain is diagnosing the problem in ways that will direct appropriate treatment and establish a more accurate prognosis. The International Classification of Disease (ICD) system (World Health Organization, 2005), which is universally accepted as a classification system for health conditions, has not been found to be particularly helpful from a prognostic standpoint or in directing interventions for back pain (Riddle DL, 1998). One of the reasons for this is that there is often a weak relationship between pathologic changes noted on imaging and an individual's level of symptomotolgy or function (Boos N et al, 200). Another reason is that again, by far, the majority of cases of low back pain can be considered non-specific and are not attributable to serious underlying pathology. So there is a need for new models of diagnosis that are more meaningful.

One of the themes of this chapter is that the diagnostic process is central to the overall management of back pain. It is a pivotal point around which clinical decisions are rendered.

Conservative Management of Low Back Pain 201

back pain is a symptom in need of treatment and more likely to view back pain as a common human experience that involves the whole person – including the individual's perceptions about their condition. With the exception of cases that involve serious pathology, people with back pain need to learn how to help themselves. To this end, education is singularly the most important "treatment" for the conservative care provider. This chapter will explore the various elements of comprehensive conservative management of back pain. There are three general elements of patient management that comprise

These elements are sequential and inter-related. In addition, to complete the cycle, outcomes of care must be assessed. An episode of care is complete when outcomes are favorable and treatment goals are met. When goals are not met, any or all elements of patient management

A comprehensive patient examination is essential for conservative management of back pain. The art and science of the clinical exam has been lost for many health care practitioners, which seems to parallel the advancement in technology – especially technology related to diagnostic imaging. Far too often when a person with back pain seeks medical care, emphasis is placed upon symptomology and imaging findings. It is imperative that both symptoms and imaging findings are interpreted within the context of a thorough clinical examination (Chou R et al, 2011). This will not only lead to a more accurate

Table 1 provides an overview of the major components of a comprehensive patient

History of Current Condition Oral History, Follow-Up Questions From Medical Screening

diagnosis, but will also help to limit unnecessary medical tests and procedures.

Medical Screening General Health Assessment, R/O Serious Pathology

Functional Outcomes Measures Oswestry Disability Index, Rolland Morris Scale

Active Movement Testing Cardinal Plane Movements, Repeated Movements

Muscle Performance Testing Abdominal/Back Extensor Strength , Gluteal Strength

Orthopedic Special Tests Straight Leg Raise, Slump Test, Prone Lumbar Instability

Review of Paraclinical data Medical reports, imaging results

Neurological Screening Reflexes, Myotomes, Dermatomes

Muscle Length Testing Hamstring, Hip Flexors, Hip Adductors

Test

Palpation Lumbar Paraspinal Muscles, Myofascial Pain

Observation & Postural Assessment Standing and Sitting

Joint Mobility Assessment P-A Vertebral Pressures

Table 1. Comprehensive Patient Examination

comprehensive care for the health care practitioner:

 Patient Examination Diagnostic Process Intervention

may have to be revisited.

**2. Patient examination** 

**Exam Item Example** 

examination.

Diagnostic classification systems for back pain have been developed within various health professions due to the need to look beyond the pathology-based orientation and for the purpose of guiding clinical decisions for spine management. For example, the McKenzie system, utilized most extensively in physical therapy, places patients with back pain into one of several categories or subcategories based upon their response to specific spinal movements (McKenzie RA, 1981). The selection of intervention is based upon the patient category. There are numerous other systems that have been developed as well. Each system possesses its own set of rules and each will direct different types of interventions. The end result of having so many different approaches to treating back pain is that it creates considerable clinical variance in back pain management. Nonetheless, the diagnostic process is the key to effectively treating back pain.

A second theme of this chapter is that a comprehensive diagnostic system for back pain must be consistent with a biopsychosocial model of healthcare and it must incorporate a person's level of function. The International Classification of Functioning, Disability and Health (ICF) provides an expanded system of classification and offers a broader perspective on the inter-relationships between health conditions and function (World Health Organization, 2008). Although the ICF is not currently being widely used as a diagnostic system for back pain, the codification scheme found in the ICF may help the health care community better understand the relationships between health conditions and functioning in the future. This system will be discussed in more detail later in the chapter.

There is a growing body of evidence that for most people who experience back pain, conservative care should placed front and center in the overall management of their problem. In addition, patient response to conservative care is being used more and more in the decision-making process relative to the need for surgical intervention (Chou R et al, 2011). In other words, people that fail to improve after a course of conservative care are more likely to benefit from surgery.

So how is conservative care defined? Conservative care may be viewed differently depending upon the orientation or discipline of the health care practitioner. For the conservative care practitioner, it would likely include only non-surgical treatment options. For the purposes of this chapter, conservative care will be defined as follows: *conservative care is the least invasive treatment for a given condition that can be justified based upon a preponderance of the evidence.* 

Conservative care for back pain can take many forms, especially if one considers complimentary and alternative medicine options. If only licensed health care professionals are considered, physical therapists and chiropractors together account for the largest groups of providers that offer comprehensive conservative care. Although the two professions differ in many significant ways, especially with regard to philosophic underpinnings, there is at the same time considerable overlap in the types of treatment rendered by these providers. As will be discussed, conservative management is more than just specific treatment approaches; it is the entire framework for understanding back pain, evaluating and diagnosing back problems, and directing treatment.

Conservative care practitioners are in the best position to help reverse the trend in developed countries to over-treat back pain. These practitioners are less likely to believe that back pain is a symptom in need of treatment and more likely to view back pain as a common human experience that involves the whole person – including the individual's perceptions about their condition. With the exception of cases that involve serious pathology, people with back pain need to learn how to help themselves. To this end, education is singularly the most important "treatment" for the conservative care provider.

This chapter will explore the various elements of comprehensive conservative management of back pain. There are three general elements of patient management that comprise comprehensive care for the health care practitioner:


200 Low Back Pain

Diagnostic classification systems for back pain have been developed within various health professions due to the need to look beyond the pathology-based orientation and for the purpose of guiding clinical decisions for spine management. For example, the McKenzie system, utilized most extensively in physical therapy, places patients with back pain into one of several categories or subcategories based upon their response to specific spinal movements (McKenzie RA, 1981). The selection of intervention is based upon the patient category. There are numerous other systems that have been developed as well. Each system possesses its own set of rules and each will direct different types of interventions. The end result of having so many different approaches to treating back pain is that it creates considerable clinical variance in back pain management. Nonetheless, the diagnostic process

A second theme of this chapter is that a comprehensive diagnostic system for back pain must be consistent with a biopsychosocial model of healthcare and it must incorporate a person's level of function. The International Classification of Functioning, Disability and Health (ICF) provides an expanded system of classification and offers a broader perspective on the inter-relationships between health conditions and function (World Health Organization, 2008). Although the ICF is not currently being widely used as a diagnostic system for back pain, the codification scheme found in the ICF may help the health care community better understand the relationships between health conditions and functioning

There is a growing body of evidence that for most people who experience back pain, conservative care should placed front and center in the overall management of their problem. In addition, patient response to conservative care is being used more and more in the decision-making process relative to the need for surgical intervention (Chou R et al, 2011). In other words, people that fail to improve after a course of conservative care are

So how is conservative care defined? Conservative care may be viewed differently depending upon the orientation or discipline of the health care practitioner. For the conservative care practitioner, it would likely include only non-surgical treatment options. For the purposes of this chapter, conservative care will be defined as follows: *conservative care is the least invasive treatment for a given condition that can be justified based upon a* 

Conservative care for back pain can take many forms, especially if one considers complimentary and alternative medicine options. If only licensed health care professionals are considered, physical therapists and chiropractors together account for the largest groups of providers that offer comprehensive conservative care. Although the two professions differ in many significant ways, especially with regard to philosophic underpinnings, there is at the same time considerable overlap in the types of treatment rendered by these providers. As will be discussed, conservative management is more than just specific treatment approaches; it is the entire framework for understanding back pain, evaluating

Conservative care practitioners are in the best position to help reverse the trend in developed countries to over-treat back pain. These practitioners are less likely to believe that

in the future. This system will be discussed in more detail later in the chapter.

is the key to effectively treating back pain.

more likely to benefit from surgery.

and diagnosing back problems, and directing treatment.

*preponderance of the evidence.* 

These elements are sequential and inter-related. In addition, to complete the cycle, outcomes of care must be assessed. An episode of care is complete when outcomes are favorable and treatment goals are met. When goals are not met, any or all elements of patient management may have to be revisited.

#### **2. Patient examination**

A comprehensive patient examination is essential for conservative management of back pain. The art and science of the clinical exam has been lost for many health care practitioners, which seems to parallel the advancement in technology – especially technology related to diagnostic imaging. Far too often when a person with back pain seeks medical care, emphasis is placed upon symptomology and imaging findings. It is imperative that both symptoms and imaging findings are interpreted within the context of a thorough clinical examination (Chou R et al, 2011). This will not only lead to a more accurate diagnosis, but will also help to limit unnecessary medical tests and procedures.

Table 1 provides an overview of the major components of a comprehensive patient examination.


Table 1. Comprehensive Patient Examination



Conservative Management of Low Back Pain 205

contains the essential information that is to be collected during the history. At the completion of the interview, it can be very insightful for the clinician to query the patient on their own views of what is causing their back pain. This is particularly important when the patient has sought care from a number of different providers. Many times, the patient has received opinions from these providers that reflect a variety of perspectives on back pain and this can lead to confusion as the patient attempts to resolve conflicting information. Patients also often misinterpret information. A person's beliefs about their problem can be a

Observation and postural assessment is where the physical examination of the patient begins. The primary objectives of observation/postural assessment in a person with back pain is to determine: (1) the general orientation of the spine and extremities in space, (2) if there are impairments related to structural alignment, (3) if there is muscle atrophy, joint or tissue swelling, or skin discoloration, and (4) how posture may be contributing to the patient problem. In many, if not most cases of back pain, the condition is caused by accumulated stress on the spine, which is in turn due to the way in which the individual functions day in and day out. For example, work demands for many people entail prolonged sitting or standing postures. If the orientation of the body in space or alignment of body segments lacks efficiency from a movement health standpoint, tissues are exposed to excessive loading. Accumulated stress can overload body tissues, which can lead to tissue breakdown and eventually symptoms of back pain. The clinician should note any significant findings, then correlate these findings with the patient's symptoms and other physical findings.

Assessment of the patient's range of motion and symptomatic response to trunk movement contributes a great deal to a movement system diagnosis of back pain. For some clinicians, it is the most critical aspect of the physical examination for both diagnosis and treatment. Figure 2 contains the most basic trunk movements assessed. Single plane, multi-plane, and repeated movements are performed during this portion of the exam. Most of the time, active movement testing begins in the standing position. Baseline pain level, utilizing the numeric pain rating scale, and location is established before active movement is performed. Symptomatic responses can include: increased, decreased, no effect, and produced. The clinician should note whether pain occurs through the range of movement or only at end range. Range of motion measurement in the clinic setting is most reliable and valid when obtained with an Inclinometer (Saur PM et al, 1996). The quality of the movement is also noted. Aberrant movement, such as the presence of a painful arc or frontal plane deviations associated with trunk flexion, can indicate lumbar instability (Hicks GE et al, 2005). Quality of movement can be assessed in other ways as well. For example, does the patient flex primarily at the hip joint and avoid thoraco-lumbar flexion? Or, is there excessive lumbar flexion? Upon return to neutral from the flexed position, does the patient initiate the movement with the hip extensors, or the trunk extensors? Quality of movement assessment

In addition, the clinician may evaluate how extremity joint movement impacts back symptoms and spine movement in order to obtain more detailed information. For example,

reveals a great deal about movement strategies (Sahrmann SA, 2002).

significant factor in their overall prognosis for recovery.

**2.5 Observation & postural assessment** 

**2.6 Active movement testing** 

this prior care can be very useful to the clinician conducting the patient examination. The clinician should make an effort to obtain this information and review it as part of the examination process. Any conflicting information should be rectified. Otherwise, the data can be added to the rest of the clinical findings during the course of the patient examination and ultimately corroborated during the diagnostic process.

#### **2.3 Functional outcome measures**

It is very important to assess the level of disability associated with an episode of back pain. The standard way to obtain this information is through self-report disability scales. Several of these types of scales have been established as both reliable and valid measures, such as the Oswestry Disability Index (Vlanin M, 2008). Scores derived from these measures can be used to determine a level of disability ranging from mild to severe. The Roland Morris Disability Index is another self-report disability tool that is clinically useful (Roland M, Morris R, 1983). A simple scale that can be used for any patient with back pain is the *Patient Specific Functional Scale.* This scale has been studied for its psychometric qualities more for cervical spine conditions (Cleland JA et al, 2006), however use of this scale insures that the function being measured is meaningful to the patient. These scales can complement one another (Beurskens AJHM et al, 1996). There are other ways of evaluating a patient's level of function. Direct measures, or performance tests, can also be conducted. Examples of performance tests for back pain include assessment of bending and lifting tasks. All of these tests should be utilized to evaluate treatment outcomes, and may be the most valuable measures of treatment effectiveness.

#### **2.4 History of current condition**

The health care provider must obtain an accurate and complete history from the patient seeking care for back pain. The patient interview can provide pivotal information that is then used by the clinician to diagnose the patient problem. This interview is both an art and a science. Good communication skills are essential. The history usually begins as an openended question such as "so tell me about your problem". The value of an open-ended question is that the patient has an opportunity to tell their "story" and often it is an efficient way to collect critical information. Follow-up questions can then begin. Sometimes patients provide extraneous information and may need to be directed by the clinician. Table 2


Table 2. Essential Information Obtained in History

this prior care can be very useful to the clinician conducting the patient examination. The clinician should make an effort to obtain this information and review it as part of the examination process. Any conflicting information should be rectified. Otherwise, the data can be added to the rest of the clinical findings during the course of the patient examination

It is very important to assess the level of disability associated with an episode of back pain. The standard way to obtain this information is through self-report disability scales. Several of these types of scales have been established as both reliable and valid measures, such as the Oswestry Disability Index (Vlanin M, 2008). Scores derived from these measures can be used to determine a level of disability ranging from mild to severe. The Roland Morris Disability Index is another self-report disability tool that is clinically useful (Roland M, Morris R, 1983). A simple scale that can be used for any patient with back pain is the *Patient Specific Functional Scale.* This scale has been studied for its psychometric qualities more for cervical spine conditions (Cleland JA et al, 2006), however use of this scale insures that the function being measured is meaningful to the patient. These scales can complement one another (Beurskens AJHM et al, 1996). There are other ways of evaluating a patient's level of function. Direct measures, or performance tests, can also be conducted. Examples of performance tests for back pain include assessment of bending and lifting tasks. All of these tests should be utilized to evaluate treatment outcomes, and may be the most valuable

The health care provider must obtain an accurate and complete history from the patient seeking care for back pain. The patient interview can provide pivotal information that is then used by the clinician to diagnose the patient problem. This interview is both an art and a science. Good communication skills are essential. The history usually begins as an openended question such as "so tell me about your problem". The value of an open-ended question is that the patient has an opportunity to tell their "story" and often it is an efficient way to collect critical information. Follow-up questions can then begin. Sometimes patients provide extraneous information and may need to be directed by the clinician. Table 2

and ultimately corroborated during the diagnostic process.

**2.3 Functional outcome measures** 

measures of treatment effectiveness.

**2.4 History of current condition** 

**Mechanism of onset/injury** 

**Previous history of back pain** 

**Symptom behavior (24 hour) Aggravating/Relieving factors Previous diagnostic tests Previous treatment** 

**Occupation/Work environment Level of physical activity** 

**Location and characteristics of symptoms** 

Table 2. Essential Information Obtained in History

**Length of time since onset of symptoms for current condition** 

**If recurrent, number and typical length of time of episodes** 

contains the essential information that is to be collected during the history. At the completion of the interview, it can be very insightful for the clinician to query the patient on their own views of what is causing their back pain. This is particularly important when the patient has sought care from a number of different providers. Many times, the patient has received opinions from these providers that reflect a variety of perspectives on back pain and this can lead to confusion as the patient attempts to resolve conflicting information. Patients also often misinterpret information. A person's beliefs about their problem can be a significant factor in their overall prognosis for recovery.

#### **2.5 Observation & postural assessment**

Observation and postural assessment is where the physical examination of the patient begins. The primary objectives of observation/postural assessment in a person with back pain is to determine: (1) the general orientation of the spine and extremities in space, (2) if there are impairments related to structural alignment, (3) if there is muscle atrophy, joint or tissue swelling, or skin discoloration, and (4) how posture may be contributing to the patient problem. In many, if not most cases of back pain, the condition is caused by accumulated stress on the spine, which is in turn due to the way in which the individual functions day in and day out. For example, work demands for many people entail prolonged sitting or standing postures. If the orientation of the body in space or alignment of body segments lacks efficiency from a movement health standpoint, tissues are exposed to excessive loading. Accumulated stress can overload body tissues, which can lead to tissue breakdown and eventually symptoms of back pain. The clinician should note any significant findings, then correlate these findings with the patient's symptoms and other physical findings.

#### **2.6 Active movement testing**

Assessment of the patient's range of motion and symptomatic response to trunk movement contributes a great deal to a movement system diagnosis of back pain. For some clinicians, it is the most critical aspect of the physical examination for both diagnosis and treatment. Figure 2 contains the most basic trunk movements assessed. Single plane, multi-plane, and repeated movements are performed during this portion of the exam. Most of the time, active movement testing begins in the standing position. Baseline pain level, utilizing the numeric pain rating scale, and location is established before active movement is performed. Symptomatic responses can include: increased, decreased, no effect, and produced. The clinician should note whether pain occurs through the range of movement or only at end range. Range of motion measurement in the clinic setting is most reliable and valid when obtained with an Inclinometer (Saur PM et al, 1996). The quality of the movement is also noted. Aberrant movement, such as the presence of a painful arc or frontal plane deviations associated with trunk flexion, can indicate lumbar instability (Hicks GE et al, 2005). Quality of movement can be assessed in other ways as well. For example, does the patient flex primarily at the hip joint and avoid thoraco-lumbar flexion? Or, is there excessive lumbar flexion? Upon return to neutral from the flexed position, does the patient initiate the movement with the hip extensors, or the trunk extensors? Quality of movement assessment reveals a great deal about movement strategies (Sahrmann SA, 2002).

In addition, the clinician may evaluate how extremity joint movement impacts back symptoms and spine movement in order to obtain more detailed information. For example,

referral.

Patellar Achilles

Ankle

(S1)

Hip Flexion (L2) Knee Extension (L3) Ankle Dorsiflexion (L4) Great Toe Extension (L5)

Plantarflexion/Eversion

Knee Flexion (S2)

 Light Touch Other

Fig. 3. Neurological Testing Lumbar Spine

considered during examination of a person with back pain.

**2.8 Muscle performance testing** 

Conservative Management of Low Back Pain 207

Neurological impairments need to be considered in the context of the patient's mechanism of onset, symptoms and other clinical findings. Positive neurological signs must be considered in the differential diagnosis, and may serve to prompt appropriate medical

**REFLEXES RIGHT LEFT** 

**LUMBAR MYOTOMES RIGHT LEFT** 

**SENSATION:** L1/L2/L3/L4/L5/S1/S2 Dermatomes

There are many ways to evaluate muscle strength, including dynamometry, manually applied resistance, EMG and isokinetic testing. The most practical and common method in the outpatient clinic setting is manual muscle testing. It is important to be selective in this portion of the patient examination since muscle strength tests can be provocative; in some cases muscle testing should be deferred if the patient's condition is irritable. The determination of specific tests is based upon information gleaned primarily from the posture and active movement assessments. Muscle atrophy and left versus right muscle asymmetries can be observed during the static standing posture analysis. During active movement, motor recruitment patterns can lead the examiner to identify both weak and dominant muscles or muscle groups. The examiner can then confirm these findings through direct assessment of muscle function. Most muscles or muscle groups can be isolated during manual testing to a reasonable degree, (Kendall FP et al, 1993) although complete isolation is not possible. For people with back pain there are key muscle groups that should be given consideration, including the back extensors, abdominals (upper and lower divisions), hip extensors, hip abductors and hip flexors. Figure 4 provides a list of muscles typically

in standing can the patient perform unilateral hip and knee flexion without rotating the lumbar spine and without pain? If the examiner controls the impaired spine movement, can the corrective movement be performed without provoking symptoms? Test items can be chosen based upon the most frequent functional movements the patient performs, or those that are reported to reproduce symptoms.


#### **COMBINED MOVEMENTS:**

#### **REPEATED MOVEMENTS**:

#### **PERIPHERAL JOINT SCREEN:**

#### Fig. 2. Active Movement Testing

Limitations in range of movement and/or joint mobility, and altered motor control contribute to altered movement patterns of the spine. A movement system diagnosis relies heavily on the clinical picture that emerges during active movement testing. These findings are then correlated to the information gleaned during the history, particularly with symptom behavior during functional tasks, as well as muscle performance testing. Indeed, the result of this portion of the examination helps in the planning for muscle strength/length testing.

#### **2.7 Neurological screening**

A neurological screen can be considered a basic component of the physical examination of the patient with back pain. It is especially important when the patient presents with extremity pain, or with neurological symptoms such as numbness or paraesthesia. It is the discretion of the clinician to forego a neurological exam when the patient's complaint is local spine pain in the absence of neurological symptoms. A summary of neurological tests can is presented in figure 3.

in standing can the patient perform unilateral hip and knee flexion without rotating the lumbar spine and without pain? If the examiner controls the impaired spine movement, can the corrective movement be performed without provoking symptoms? Test items can be chosen based upon the most frequent functional movements the patient performs, or those

Limitations in range of movement and/or joint mobility, and altered motor control contribute to altered movement patterns of the spine. A movement system diagnosis relies heavily on the clinical picture that emerges during active movement testing. These findings are then correlated to the information gleaned during the history, particularly with symptom behavior during functional tasks, as well as muscle performance testing. Indeed, the result of this portion of the examination helps in the planning for muscle

A neurological screen can be considered a basic component of the physical examination of the patient with back pain. It is especially important when the patient presents with extremity pain, or with neurological symptoms such as numbness or paraesthesia. It is the discretion of the clinician to forego a neurological exam when the patient's complaint is local spine pain in the absence of neurological symptoms. A summary of neurological tests can is

**ROM Loss Symptomatic Response Quality of Movement** 

that are reported to reproduce symptoms.

**COMBINED MOVEMENTS:** 

**REPEATED MOVEMENTS**:

**PERIPHERAL JOINT SCREEN:** 

Fig. 2. Active Movement Testing

strength/length testing.

presented in figure 3.

**2.7 Neurological screening** 

**TRUNK MOVEMENTS (STANDING)** 

Flexion Extension Right Lateral Flexion

Left Lateral Flexion

Right Rotation Left Rotation Right Side-Glide Left Side-Glide Supine Flexion Prone Extension Comments:

Neurological impairments need to be considered in the context of the patient's mechanism of onset, symptoms and other clinical findings. Positive neurological signs must be considered in the differential diagnosis, and may serve to prompt appropriate medical referral.



**SENSATION:** L1/L2/L3/L4/L5/S1/S2 Dermatomes


Fig. 3. Neurological Testing Lumbar Spine

#### **2.8 Muscle performance testing**

There are many ways to evaluate muscle strength, including dynamometry, manually applied resistance, EMG and isokinetic testing. The most practical and common method in the outpatient clinic setting is manual muscle testing. It is important to be selective in this portion of the patient examination since muscle strength tests can be provocative; in some cases muscle testing should be deferred if the patient's condition is irritable. The determination of specific tests is based upon information gleaned primarily from the posture and active movement assessments. Muscle atrophy and left versus right muscle asymmetries can be observed during the static standing posture analysis. During active movement, motor recruitment patterns can lead the examiner to identify both weak and dominant muscles or muscle groups. The examiner can then confirm these findings through direct assessment of muscle function. Most muscles or muscle groups can be isolated during manual testing to a reasonable degree, (Kendall FP et al, 1993) although complete isolation is not possible. For people with back pain there are key muscle groups that should be given consideration, including the back extensors, abdominals (upper and lower divisions), hip extensors, hip abductors and hip flexors. Figure 4 provides a list of muscles typically considered during examination of a person with back pain.

Conservative Management of Low Back Pain 209

Figure 5 contains a list of special tests frequently used in the examination of the lumbar spine. This list is only representative of the numerous tests that currently exist (Magee DJ, 2002). Sensitivity and specificity data can be found in the literature for some but not all of these tests, which helps the clinician evaluate the utility of each test. Selection of tests is based upon information obtained in the history, including results of diagnostic imaging, and the clinician's hypothesis generated by the collective information from the rest of the examination. It is beyond the scope of this chapter to analyze individual tests; this

When a tissue source of pain can be discerned, it is important to include this in the diagnostic complex. This enables the health care provider to be as specific as possible in assigning an ICD code to the patient problem. It also can lead the clinician to request follow-

Impairments of joint mobility frequently accompany active range of motion (AROM) deficits, however joint mobility is considered a distinct aspect of joint movement and therefore impaired joint mobility can be present when AROM is normal. Joint mobility is assessed through passive movements imparted by the examiner. These movements can be physiologic, meaning there is a corresponding active movement associated with the passive movement, or accessory, meaning there is no associated physiologic movement. Examples of physiologic movements in the lumbar spine extension and flexion; examples of accessory

Clinical findings during joint mobility assessment that would be indicative of impairment are reproduction of the patient's symptoms, altered mobility (too much are too little movement), and/or the production of involuntary muscle guarding. Joint mobility can be categorized as: (1) Hypomobile, (2) Normal, or (3) Hypermobile. This is determined based

information can be found in standard orthopedic evaluation texts.

Prone Lumbar Instability + / - Valsalva Maneuver + / -

up tests or may lead instead to an appropriate medical referral.

movements include posterior-to-anterior glide and lateral glide.

Fig. 5. Orthopedic Special Tests

**2.11 Joint mobility assessment** 

**SPECIAL TESTS RIGHT LEFT** 

SLR + / - + / - Bragard's Test + / - + / - Lindner's Sign + / - + / - Slump Test + / - + / - Well Leg Raise + / - + / - Bowstring Test + / - + / - Bechterewis Test + / - + / - Quadrant Test + / - + / - Prone Knee Flexion + / - + / - McKenzie's Slide Glide + / - + / - Stork Standing Test + / - + / -

Knowledge of impairments of muscle performance contributes substantially to the diagnosis of movement system impairment. In addition, impaired muscle function is targeted specifically in the plan of care for the patient through corrective exercise.


Fig. 4. Muscle Strength and Length Tests

#### **2.9 Muscle length testing**

Adaptive muscle shortening can either be a consequence of impaired movement, or a contributing factor in movement dysfunction. Muscle length deficits will limit joint movement, and the joints spanned by the muscle will not be able to achieve a neutral position. Alternatively, muscles can develop stiffness, which can be defined as an increased resistance to passive movement. For muscle length testing, the examiner generally attempts to passively lengthen a muscle over the joint(s) that it crosses while ensuring stabilization of the proximal bony lever. A short muscle will be incapable of lengthening fully across the joint(s); a stiff muscle will achieve adequate length but will demonstrate increased resistance to passive stretch. In either case, the consequence of short or stiff muscles is altered and inefficient movement patterns. Further, muscle length and strength deficits tend to be interdependent and reflect, and contribute to, an imbalance of forces across joints.

As with the results of muscle performance testing, the identification of muscle length deficits will assist in the diagnosis and treatment of movement impairment.

#### **2.10 Orthopedic special tests**

The primary purpose of special tests in an orthopedic spine examination is to selectively expose the tissues to mechanical stresses in order to rule in or rule out specific musculoskeletal causes of back pain. Tissue sources of pain can then be identified. The clinician must be aware of the limitations of special tests and mindful that in many cases, a specific tissue source of pain cannot be accurately determined.

Knowledge of impairments of muscle performance contributes substantially to the diagnosis of movement system impairment. In addition, impaired muscle function is targeted

**RIGHT LEFT RIGHT LEFT** 

specifically in the plan of care for the patient through corrective exercise.

Erector Spinae Normal / short / stiff

Gluteus Maximus Normal / short / stiff Normal / short / stiff Gluteus Medius Normal / short / stiff Normal / short / stiff Psoas Normal / short / stiff Normal / short / stiff Hip Adductors Normal / short / stiff Normal / short / stiff Hamstrings Normal / short / stiff Normal / short / stiff Quadriceps Normal / short / stiff Normal / short / stiff Piriformis Normal / short / stiff Normal / short / stiff

Lumborum Normal / short / stiff Normal / short / stiff Gastroc/Soleus Normal / short / stiff Normal / short / stiff

Adaptive muscle shortening can either be a consequence of impaired movement, or a contributing factor in movement dysfunction. Muscle length deficits will limit joint movement, and the joints spanned by the muscle will not be able to achieve a neutral position. Alternatively, muscles can develop stiffness, which can be defined as an increased resistance to passive movement. For muscle length testing, the examiner generally attempts to passively lengthen a muscle over the joint(s) that it crosses while ensuring stabilization of the proximal bony lever. A short muscle will be incapable of lengthening fully across the joint(s); a stiff muscle will achieve adequate length but will demonstrate increased resistance to passive stretch. In either case, the consequence of short or stiff muscles is altered and inefficient movement patterns. Further, muscle length and strength deficits tend to be interdependent and reflect, and contribute to, an

As with the results of muscle performance testing, the identification of muscle length

The primary purpose of special tests in an orthopedic spine examination is to selectively expose the tissues to mechanical stresses in order to rule in or rule out specific musculoskeletal causes of back pain. Tissue sources of pain can then be identified. The clinician must be aware of the limitations of special tests and mindful that in many cases, a

deficits will assist in the diagnosis and treatment of movement impairment.

specific tissue source of pain cannot be accurately determined.

**MANUAL MUSCLE** 

**MUSCLE LENGTH** 

**TEST/** 

**TEST** 

Quadratus

Fig. 4. Muscle Strength and Length Tests

**2.9 Muscle length testing** 

imbalance of forces across joints.

**2.10 Orthopedic special tests** 

Figure 5 contains a list of special tests frequently used in the examination of the lumbar spine. This list is only representative of the numerous tests that currently exist (Magee DJ, 2002). Sensitivity and specificity data can be found in the literature for some but not all of these tests, which helps the clinician evaluate the utility of each test. Selection of tests is based upon information obtained in the history, including results of diagnostic imaging, and the clinician's hypothesis generated by the collective information from the rest of the examination. It is beyond the scope of this chapter to analyze individual tests; this information can be found in standard orthopedic evaluation texts.


Fig. 5. Orthopedic Special Tests

When a tissue source of pain can be discerned, it is important to include this in the diagnostic complex. This enables the health care provider to be as specific as possible in assigning an ICD code to the patient problem. It also can lead the clinician to request followup tests or may lead instead to an appropriate medical referral.

#### **2.11 Joint mobility assessment**

Impairments of joint mobility frequently accompany active range of motion (AROM) deficits, however joint mobility is considered a distinct aspect of joint movement and therefore impaired joint mobility can be present when AROM is normal. Joint mobility is assessed through passive movements imparted by the examiner. These movements can be physiologic, meaning there is a corresponding active movement associated with the passive movement, or accessory, meaning there is no associated physiologic movement. Examples of physiologic movements in the lumbar spine extension and flexion; examples of accessory movements include posterior-to-anterior glide and lateral glide.

Clinical findings during joint mobility assessment that would be indicative of impairment are reproduction of the patient's symptoms, altered mobility (too much are too little movement), and/or the production of involuntary muscle guarding. Joint mobility can be categorized as: (1) Hypomobile, (2) Normal, or (3) Hypermobile. This is determined based

Conservative Management of Low Back Pain 211

Pain with active movement

Segmental Hypomobility/ palpatory

+ neurological signs with nerve root

+ neurological signs with nerve root

Loss of active trunk extension ROM

Pain with active trunk extension Negative neurological signs Segmental hypomobiltiy

Pelvic asymmetries noted with

Pain with active trunk flexion Negative neurological signs + SI provocation tests (Thigh Thrust, Distraction) Palpatory pain in sacral sulcus Hypo or hyermobility of SI joint

Trunk ROM pain limited

Negative neurologic signs

Spinal tilt may be evident Pain with active trunk flexion Centralization of pain with trunk

multidirectional

tenderness

extension

compromise

compromise

+ nerve tension signs (SLR, Slump Test)

Pain with active trunk extension/lateral flexion

+ nerve tension signs (SLR, Slump Test)

+ neurological signs + quadrant test

(subacute phase)

palpation

At the completion of the examination phase of management, the patient data must be interpreted and a treatment plan can then be established. The critical link between analysis and intervention is diagnosis. Diagnosis is the central element of patient management and

**Condition Presenting Symptoms/History Clinical Findings** 

Pain localized to lumbar spine

Unilateral back and/or leg pain Flexion positions/postures

Pain relieved by rest

Lumbar Strain Acute trauma/microtrauma

Disc Herniation Acute or insidious onset

aggravate

Lateral Stenosis Long history of back pain

aggravate

aggravate

aggravate

aggravate

childbirth

Fig. 7. Musculoskeletal Differential Diagnosis

will be discussed next.

relieve

Central Stenosis

Facet Joint Sprain

SI Joint Syndrome Leg pain > back pain

Extension positions/postures

Bilateral leg pain/paresthesia Extension positions/postures

Flexion positions/postures

Acute trauma/microtrauma

Extension positions/postures

Flexion postures/positions

Common in women after

Unilateral back pain

Pain in lumbosacral region/buttock

upon what is considered normal for the individual; a "within person" reference standard is used as opposed to a "between person" reference standard. The 3-point scale has been found to have adequate validity and reliability (Landell R et al, 2008).

Joint mobility impairments can contribute to abnormal and inefficient active joint movement. The clinical findings during joint mobility assessment are used in the diagnostic process and to help direct treatment. In particular, decisions about whether or not the patient is a candidate for joint mobilization and manipulation are often based upon this aspect of the patient examination. Figure 6 is representative of the common accessory and physiologic movements examined in the lumbar spine.


Fig. 6. Joint Mobility Assessment

#### **2.12 Palpation**

Palpation of accessible body structures is often performed last in the physical examination due to the potential for the provocation of symptoms, particularly in more acute conditions. If symptoms are produced, increased or worse following palpation, this may influence the accuracy of other tests and measures. On the other hand, for subacute and chronic conditions, the clinician may want to start with palpation in order to better direct the remainder of the exam.

When the clinician is knowledgeable in surface anatomy and skilled in the art of palpation, this portion of the exam can provide important information relative to the tissue source of symptoms. This is particularly true for tissues that, when irritated or inflamed, produce pain that is well localized.

#### **2.13 Summary**

In the patient exam, essentially the clinician is asking a series of questions through a thoughtful selection of tests and measures. The intake data, medical screening process and history all inform this selection of tests for the physical examination. It is very important that the examination is systematized and consistent in a general way from one patient to the next. This helps to ensure that the exam is thorough and that all critical data is collected. Figure 7 provides a collection of signs and symptoms of common clinical conditions obtained through the patient examination process. This information can assist the clinician in determining specific health conditions that are contributing to the patient's low back complaints.

upon what is considered normal for the individual; a "within person" reference standard is used as opposed to a "between person" reference standard. The 3-point scale has been

Joint mobility impairments can contribute to abnormal and inefficient active joint movement. The clinical findings during joint mobility assessment are used in the diagnostic process and to help direct treatment. In particular, decisions about whether or not the patient is a candidate for joint mobilization and manipulation are often based upon this aspect of the patient examination. Figure 6 is representative of the common accessory and

P-A Central Vertebral Pressure Normal / hypo / hyper Normal / hypo / hyper P-A Unilateral Vertebral Pressure Normal / hypo / hyper Normal / hypo / hyper Transverse Vertebral Pressure Normal / hypo / hyper Normal / hypo / hyper Flexion Normal / hypo / hyper Normal / hypo / hyper Extension Normal / hypo / hyper Normal / hypo / hyper Side Flexion Normal / hypo / hyper Normal / hypo / hyper Rotation Normal / hypo / hyper Normal / hypo / hyper

Palpation of accessible body structures is often performed last in the physical examination due to the potential for the provocation of symptoms, particularly in more acute conditions. If symptoms are produced, increased or worse following palpation, this may influence the accuracy of other tests and measures. On the other hand, for subacute and chronic conditions, the clinician may want to start with palpation in order to better direct the

When the clinician is knowledgeable in surface anatomy and skilled in the art of palpation, this portion of the exam can provide important information relative to the tissue source of symptoms. This is particularly true for tissues that, when irritated or inflamed, produce pain

In the patient exam, essentially the clinician is asking a series of questions through a thoughtful selection of tests and measures. The intake data, medical screening process and history all inform this selection of tests for the physical examination. It is very important that the examination is systematized and consistent in a general way from one patient to the next. This helps to ensure that the exam is thorough and that all critical data is collected. Figure 7 provides a collection of signs and symptoms of common clinical conditions obtained through the patient examination process. This information can assist the clinician in determining specific health conditions that are contributing to the patient's low back

found to have adequate validity and reliability (Landell R et al, 2008).

**ASSESSMENT RIGHT LEFT** 

physiologic movements examined in the lumbar spine.

**JOINT MOBILITY** 

**2.12 Palpation** 

remainder of the exam.

that is well localized.

**2.13 Summary** 

complaints.

Fig. 6. Joint Mobility Assessment



At the completion of the examination phase of management, the patient data must be interpreted and a treatment plan can then be established. The critical link between analysis and intervention is diagnosis. Diagnosis is the central element of patient management and will be discussed next.

diagnosis.

Conservative Management of Low Back Pain 213

Since one point of agreement among health care professionals and researchers is that classification systems must be clinically pragmatic, there is a need for qualitative studies to explore what clinicians are actually doing in practice with regard to diagnosis. In order to fulfill this need, the author conducted a survey of physical therapists in clinical practice (Spoto MM, Collins J, 2008). A purposeful sample of physical therapists that are certified specialists in orthopedic practice was obtained. The participants were recognized for having a depth of knowledge and skill in orthopedic practice beyond that required for general practice. The general characteristics of the subjects can be found in table 3. These subjects were asked to answer both open and close-ended questions about how they approach

**Primary Practice Setting Secondary Practice Setting Years in** 

*Consultant* 0% *Consultant* 3%

Table 3. Subject characteristics for physical therapists

should be considered and incorporated with the ICD.

Fig. 8. Diagnosis by Physical Therapists

*Patient Care* 84% *Patient Care* 16% 3-8 18% *Teaching: Graduate* 8% *Teaching: Graduate* 25% 9-14 23% *Teaching: Postgraduate* 1% *Teaching: Postgraduate* 8% 15-20 26% *Management* 6% *Management* 40% 21-26 21% *Research* 5% *Research* 3% >26 11%

The results of this study demonstrate that considerable variability is found in the way in which physical therapists classify back conditions. This is not surprising given the existence of numerous diagnostic systems in practice. In addition, over one-half of the physical therapists surveyed used more than one classification system. All of this contributes to the lack of consistency in the labels used by physical therapists to name the patient condition. Several themes emerged from this study and are summarized in figure 8. The first two themes reflect the need to move beyond the ICD and incorporate other constructs in the diagnosis. Psychiatrists and psychologists, for example, utilize a multi-axial system of diagnosis for psychological disorders in the *Diagnostic and Statistical Manual of Mental Disorders*. For back disorders, constructs such as impairments and functional limitations

**Practice** 

#### **3. Diagnosis**

Diagnosis can be considered both a process, and a label that is generated from this process. In medicine, the *International Statistical Classification of Disease and Related Health Problems*  (ICD) is utilized extensively by health care providers and most medical diagnoses are expressed as ICD codes. The ICD is a hierarchical system, whereby the most specific diagnosis is rendered that can be supported by diagnostic testing. For many musculoskeletal conditions, and especially back pain, the reliability of assigning diagnostic codes has not been studied extensively. Therefore, the reliability and validity of the coding system as a whole has not been established. The lack of consistency in categorizing patient conditions leads to clinical variance in managing conditions.

The dilemma surrounding diagnosis of back pain has significant implications, since diagnosis drives treatment decisions. Further, accurate diagnosis is essential to evaluating the effectiveness of treatments, which is a core value in evidence-based practice.

In addition to the challenges of accurate application of the ICD system, the system itself is considered inadequate in directing conservative treatment. Back pain is a largely a problem of the movement system. Back pain can occur in the absence of pathology. Many times a specific pathology cannot be identified in a person with back pain, so constructs other than pathology have to be considered in a clinically useful diagnostic system.

There are many ways in which clinicians can categorize back pain that fall outside the traditional ICD system. Numerous systems have been developed over the years within the professions involved in managing back pain, including medical primary care, physical therapy and chiropractic. Physical therapists in particular are on the front lines of conservative musculoskeletal care. In the physical therapy profession, a practical need exists to find a way to create subgroups of patients for the purpose of determining the most targeted interventions. Diagnostic systems have been developed to help fill this need. These methods of classification all vary in the constructs that serve as a basis for the categories, however there are also points of convergence. For example, patient response (symptomatic) to active movement is used to categorize patients in several of the more common systems. As expected, since the focus in conservative care is more functionally oriented, patient data derived from movement or functional testing is utilized in clinical decision-making.

The existing diagnostic classification models all have merit, however the diversity found in these systems creates variability in the way that clinical decisions are rendered. The lack of a standardized taxonomy has led to challenges not only for clinicians, but also the research community and ultimately people experiencing back pain.

Much of the research on diagnostic systems for back pain has been quantitative in nature. Several of the more common systems have undergone analysis of both reliability of assigning diagnostic categories to people with back pain, and validity of the systems. Validity has been investigated by determining if a targeted intervention is more likely to be effective when it is matched to the patient subgroup (Childs JD, 2004). These studies have begun to build a case for the usefulness of at least 3 systems used in physical therapy practice: (1) McKenzie, (2) Treatment-based, and (3) Movement System Impairment. All of these systems are structured and have explicit inclusion criteria. However little is known about how these are being used in clinical practice.

Diagnosis can be considered both a process, and a label that is generated from this process. In medicine, the *International Statistical Classification of Disease and Related Health Problems*  (ICD) is utilized extensively by health care providers and most medical diagnoses are expressed as ICD codes. The ICD is a hierarchical system, whereby the most specific diagnosis is rendered that can be supported by diagnostic testing. For many musculoskeletal conditions, and especially back pain, the reliability of assigning diagnostic codes has not been studied extensively. Therefore, the reliability and validity of the coding system as a whole has not been established. The lack of consistency in categorizing patient conditions

The dilemma surrounding diagnosis of back pain has significant implications, since diagnosis drives treatment decisions. Further, accurate diagnosis is essential to evaluating

In addition to the challenges of accurate application of the ICD system, the system itself is considered inadequate in directing conservative treatment. Back pain is a largely a problem of the movement system. Back pain can occur in the absence of pathology. Many times a specific pathology cannot be identified in a person with back pain, so constructs other than

There are many ways in which clinicians can categorize back pain that fall outside the traditional ICD system. Numerous systems have been developed over the years within the professions involved in managing back pain, including medical primary care, physical therapy and chiropractic. Physical therapists in particular are on the front lines of conservative musculoskeletal care. In the physical therapy profession, a practical need exists to find a way to create subgroups of patients for the purpose of determining the most targeted interventions. Diagnostic systems have been developed to help fill this need. These methods of classification all vary in the constructs that serve as a basis for the categories, however there are also points of convergence. For example, patient response (symptomatic) to active movement is used to categorize patients in several of the more common systems. As expected, since the focus in conservative care is more functionally oriented, patient data

derived from movement or functional testing is utilized in clinical decision-making.

community and ultimately people experiencing back pain.

about how these are being used in clinical practice.

The existing diagnostic classification models all have merit, however the diversity found in these systems creates variability in the way that clinical decisions are rendered. The lack of a standardized taxonomy has led to challenges not only for clinicians, but also the research

Much of the research on diagnostic systems for back pain has been quantitative in nature. Several of the more common systems have undergone analysis of both reliability of assigning diagnostic categories to people with back pain, and validity of the systems. Validity has been investigated by determining if a targeted intervention is more likely to be effective when it is matched to the patient subgroup (Childs JD, 2004). These studies have begun to build a case for the usefulness of at least 3 systems used in physical therapy practice: (1) McKenzie, (2) Treatment-based, and (3) Movement System Impairment. All of these systems are structured and have explicit inclusion criteria. However little is known

the effectiveness of treatments, which is a core value in evidence-based practice.

pathology have to be considered in a clinically useful diagnostic system.

**3. Diagnosis** 

leads to clinical variance in managing conditions.

Since one point of agreement among health care professionals and researchers is that classification systems must be clinically pragmatic, there is a need for qualitative studies to explore what clinicians are actually doing in practice with regard to diagnosis. In order to fulfill this need, the author conducted a survey of physical therapists in clinical practice (Spoto MM, Collins J, 2008). A purposeful sample of physical therapists that are certified specialists in orthopedic practice was obtained. The participants were recognized for having a depth of knowledge and skill in orthopedic practice beyond that required for general practice. The general characteristics of the subjects can be found in table 3. These subjects were asked to answer both open and close-ended questions about how they approach diagnosis.


Table 3. Subject characteristics for physical therapists

The results of this study demonstrate that considerable variability is found in the way in which physical therapists classify back conditions. This is not surprising given the existence of numerous diagnostic systems in practice. In addition, over one-half of the physical therapists surveyed used more than one classification system. All of this contributes to the lack of consistency in the labels used by physical therapists to name the patient condition. Several themes emerged from this study and are summarized in figure 8. The first two themes reflect the need to move beyond the ICD and incorporate other constructs in the diagnosis. Psychiatrists and psychologists, for example, utilize a multi-axial system of diagnosis for psychological disorders in the *Diagnostic and Statistical Manual of Mental Disorders*. For back disorders, constructs such as impairments and functional limitations should be considered and incorporated with the ICD.

Fig. 8. Diagnosis by Physical Therapists

Conservative Management of Low Back Pain 215

studies investigating the effectiveness of non-pharmacologic conservative treatments are designed to compare one intervention to either another intervention, or to no treatment. Since a single type of intervention is not likely to demonstrate a large treatment effect, especially when compared to another single-modal intervention, there is a need to develop a larger pool of high-quality studies investigating overall conservative management strategies. Another challenge is that in clinical trials investigating effectiveness of interventions for people with back pain, research subjects are often heterogeneous – reflecting the lack of a standard way to categorize back conditions. There is a growing pool of evidence that when similar groups are studied, and interventions are matched to treatment subgroups, outcomes are better (Childs JD et al, 2004). Figure 10 provides common treatment categories and the patient characteristics that would predict success with

Relatively acute pain

Local Pain Low FABQ Score

< 40 years of age

Episodic/recurring pain Aberrant trunk movements

No directional preference

Lumbar intersegmental hypomobility

Lumbar intersegmental hypermobility

Directional preference (extension/flexion) Centralization with active movement tests

Peripheralization with active movement

Fig. 10. Treatment-based classification: matching interventions to patient subgroups

Parallel to the challenge of providing high quality evidence supporting the effectiveness of conservative interventions for back pain, however, is the growing speculation about the role of invasive medical procedures in treating back pain. A recent study that investigated treatment outcomes of injured workers found that back patients that underwent spinal fusion had worse outcomes at 2 years compared to those receiving conservative care (Nguyen TH et al, 2011). These findings should be taken within the context of the considerable increase in both risk and cost for invasive treatments. Martin and Deyo have recently provided an interesting cost analysis of spine care in the US. They found that costs associated with spine care have risen substantially over the past decade and that there is no corresponding improvement in health status for people with spine problems (Martin BI, Deyo RA, 2008). The medical profession needs to develop evidence-based criteria for surgical intervention, in particular, by identifying the patient characteristics that predict success with surgical management. With ever increasing medical costs associated with

Radicular pain

the specific types of conservative interventions.

Manipulation

Lumbar Stabilization

Specific Exercise

Traction

Treatment Group Patient Profile

For physical therapists, diagnosis tends to be process-oriented. The various classification systems all have rules for interpreting patient data in ways that direct treatment. Until a more standard system is developed, with explicit criteria for selecting diagnostic categories, physical therapists engage in clinical reasoning to derive treatment decisions. Clinical reasoning, supported by the rules that govern the diagnostic system, is essentially the diagnostic process. Further, physical therapists indicate that they believe the primary role of diagnosis is to determine appropriate treatment. Since the overarching goal of treatment is to restore function, diagnosis must address (movement) function.

Fig. 9. ICF Model of Functioning & Health

A multidisciplinary model of functioning has been established in the *International Classification of Functioning, Disease and Health* (ICF). The ICF framework includes multiple factors or components that contribute to human functioning and health (WHO, 2008). Health conditions or diseases comprise one aspect of a person's health, however health conditions interact with body functions, both at the individual parts (tissues, joint, body part) and whole person levels, and these in turn interact with personal and environmental factors. The ICF framework is an expanded and more accurate way to define and address both health and disability. There are efforts ongoing in the health care professions to incorporate this new model into diagnostic classification systems for musculoskeletal conditions (Childs JD et al, 2008).

It is clear that health care providers recognize the need for a more meaningful way to approach diagnosis of back problems. Given that the ICD and ICF coding systems are universal, it seems reasonable that the constructs expressed in these systems could be integrated so that all components of health and disability are captured, and meaningful subgroups of back problems can emerge. In the meantime, conservative care practitioners will continue to use clinical subgroups, comprising clusters of signs and symptoms, to categorize patients in order to direct appropriate treatment.

#### **4. Conservative intervention (Non-pharmacologic)**

The conservative practitioner generally employs a combination of interventions in the treatment of back pain. A multi-modal approach is most common. Many of the research

For physical therapists, diagnosis tends to be process-oriented. The various classification systems all have rules for interpreting patient data in ways that direct treatment. Until a more standard system is developed, with explicit criteria for selecting diagnostic categories, physical therapists engage in clinical reasoning to derive treatment decisions. Clinical reasoning, supported by the rules that govern the diagnostic system, is essentially the diagnostic process. Further, physical therapists indicate that they believe the primary role of diagnosis is to determine appropriate treatment. Since the overarching goal of treatment is

A multidisciplinary model of functioning has been established in the *International Classification of Functioning, Disease and Health* (ICF). The ICF framework includes multiple factors or components that contribute to human functioning and health (WHO, 2008). Health conditions or diseases comprise one aspect of a person's health, however health conditions interact with body functions, both at the individual parts (tissues, joint, body part) and whole person levels, and these in turn interact with personal and environmental factors. The ICF framework is an expanded and more accurate way to define and address both health and disability. There are efforts ongoing in the health care professions to incorporate this new model into diagnostic classification systems for musculoskeletal

It is clear that health care providers recognize the need for a more meaningful way to approach diagnosis of back problems. Given that the ICD and ICF coding systems are universal, it seems reasonable that the constructs expressed in these systems could be integrated so that all components of health and disability are captured, and meaningful subgroups of back problems can emerge. In the meantime, conservative care practitioners will continue to use clinical subgroups, comprising clusters of signs and symptoms, to

The conservative practitioner generally employs a combination of interventions in the treatment of back pain. A multi-modal approach is most common. Many of the research

to restore function, diagnosis must address (movement) function.

Fig. 9. ICF Model of Functioning & Health

conditions (Childs JD et al, 2008).

categorize patients in order to direct appropriate treatment.

**4. Conservative intervention (Non-pharmacologic)** 

studies investigating the effectiveness of non-pharmacologic conservative treatments are designed to compare one intervention to either another intervention, or to no treatment. Since a single type of intervention is not likely to demonstrate a large treatment effect, especially when compared to another single-modal intervention, there is a need to develop a larger pool of high-quality studies investigating overall conservative management strategies. Another challenge is that in clinical trials investigating effectiveness of interventions for people with back pain, research subjects are often heterogeneous – reflecting the lack of a standard way to categorize back conditions. There is a growing pool of evidence that when similar groups are studied, and interventions are matched to treatment subgroups, outcomes are better (Childs JD et al, 2004). Figure 10 provides common treatment categories and the patient characteristics that would predict success with the specific types of conservative interventions.


Fig. 10. Treatment-based classification: matching interventions to patient subgroups

Parallel to the challenge of providing high quality evidence supporting the effectiveness of conservative interventions for back pain, however, is the growing speculation about the role of invasive medical procedures in treating back pain. A recent study that investigated treatment outcomes of injured workers found that back patients that underwent spinal fusion had worse outcomes at 2 years compared to those receiving conservative care (Nguyen TH et al, 2011). These findings should be taken within the context of the considerable increase in both risk and cost for invasive treatments. Martin and Deyo have recently provided an interesting cost analysis of spine care in the US. They found that costs associated with spine care have risen substantially over the past decade and that there is no corresponding improvement in health status for people with spine problems (Martin BI, Deyo RA, 2008). The medical profession needs to develop evidence-based criteria for surgical intervention, in particular, by identifying the patient characteristics that predict success with surgical management. With ever increasing medical costs associated with

Conservative Management of Low Back Pain 217

interventions for back pain, Chou suggests that manipulation, along with cognitive behavioral therapy, exercise and interdisciplinary rehabilitation, is moderately effective in reducing pain and improving function in people with acute or chronic back pain (Chou R , Huffman LH, 2007). A recent systematic review, however, concludes that spinal manipulation has a small effect on pain and function compared to other interventions, and

A clinical prediction rule has been established to better predict which patients respond favorably to manipulation (Flynn T A, 2002). Predictors of success with manipulation can be found in table 4. The positive Likelihood Ratio (LR) for the presence of 4 or more patient characteristics is 24, indicating that when patients meet the criteria, they have a very good chance of responding positively to manipulation. This rule has undergone validation studies, which support the contention that when patients are placed in subgroups based upon their presenting signs/symptoms and exam findings, treatment can be better targeted

It is worthy to note that all national clinical guidelines for low back pain address spinal manipulation, although the recommendations vary. The majority of countries recommend

Spinal manipulation is a safe, conservative care option for the treatment of back pain. There are few contraindications, however: the presence of serious underling pathology, advanced osteoporosis, infection and cauda equina syndrome would be considered absolute contraindications to spinal manipulation. The mechanisms of action of manipulation are not fully understood, however currently it is believed that there are both mechanical and non-

In general, manipulation has been found to have a small to moderate effect on decreasing pain and improving function in people with back pain. Most conservative care practitioners who perform spinal manipulation employ other types of interventions when treating back pain. Finally, clinical decision rules can be used to help identify which patients are likely to respond favorably to manipulation. Table 4 summarizes the patient characteristics that would predict success with a treatment program that includes spinal manipulation. The likelihood of the patient benefiting from manipulation increases in relation to the number of criteria met; if patients meet all or most criteria they have a high probability of improving

Exercise interventions, along with patient education, are foundational in the conservative approach to treating musculoskeletal conditions of the spine. It is through exercise that body

that this difference is not clinically significant (Rubinstein SM et al, 2007).

to their condition and outcomes will improve (Childs et al, 2004).

Hypomobility of at least one lumbar segmental level At least one hip with >35 degrees of internal rotation Fear-Avoidance Belief Questionnaire work score <19

Table 4. Clinical Prediction Rule for Spinal Manipulation

Patient Characteristics

mechanical effects.

with manipulation.

**4.2 Exercise** 

Duration of symptoms < 16 days No symptoms distal to the knee

manipulation for the treatment of acute low back pain (Bigos S et al, 1994).

musculoskeletal care, the current focus should be on finding the most cost effective treatments.

There is growing support in the literature for multi-modal, conservative treatment of spine pain (UK BEAM Trail Team, 2004). With the pursuit of more meaningful ways to categorize back disorders combined with more pragmatic clinical trials – where the focus is on studying overall management strategies rather than specific interventions – there is likely to be higher quality evidence in support of conservative intervention for the majority of people with back disorders.

Conservative interventions considered here will include the most common treatments utilized in practice: (1) Joint Mobilization/Manipulation, (2) Exercise Interventions, (3) Patient Education, (4) Physical Modalities, (5) Cognitive-Behavioral Interventions, and (6) Traction. A description of each intervention and a summary of the evidence on effectiveness will follow.

#### **4.1 Joint mobilization/manipulation**

Joint mobilization can be defined as: "a manual therapy technique comprising a continuum of passive movements to the joints and/or related soft tissues that are applied at various speeds and amplitudes, **including a small amplitude, high velocity therapeutic movement**" (APTA, 1997). Joint mobilization encompasses manipulation since manipulation is generally considered specifically the small amplitude, high velocity movement imparted to a joint. Another way of expressing this is to distinguish between "Non-Thrust" and "Thrust" techniques, the former referring to mobilization and the latter manipulation.

Joint mobilization is utilized to treat primarily impairments of joint mobility, range of motion and pain. Many disciplines employ joint mobilization, including the professions of chiropractic, physical therapy, osteopathy and medicine. Manipulative therapy has been studied extensively and therefore a high volume of information can be found on the topic. There has been great interest in better understanding the mechanisms of action of manipulation, and in investigating the effectiveness of manipulation in treating back pain.

The mechanisms of action of spine manipulation can be broadly divided into (1) mechanical and (2) non-mechanical effects. Although there have been many theories relative to the mechanical effects of manipulation over the years, recent evidence based upon more direct measurement of spine movement supports the conclusion that thrust techniques result in multi-axial intervertebral displacements. These displacements increase in association with the applied force and occur at multiple segmental levels (Keller TS et al, 2003). This suggests that a manipulative force will impact an entire spinal region as opposed to a specific segmental level. However it is common practice to apply the force to the most restricted segmental level, determined by joint mobility assessment findings. Non-mechanical effects of manipulation are thought to be related to altered pain processing, both at the peripheral and central nervous system levels. A Hypoalgesic effect has been found to occur immediately following joint manipulation (Bialosky JE et al 2008). Also of interest is the somewhat paradoxical effect of manipulation to either increase motorneuron firing, when it is desirable to facilitate deep segmental muscle activity for example, or decrease motorneuron firing when heightened muscle activity is unwanted (Colloca CJ et al, 2006).

Numerous clinical trials have been conducted investigating the effectiveness of manipulation for treating back pain. In a systematic review of non-pharmacologic

musculoskeletal care, the current focus should be on finding the most cost effective

There is growing support in the literature for multi-modal, conservative treatment of spine pain (UK BEAM Trail Team, 2004). With the pursuit of more meaningful ways to categorize back disorders combined with more pragmatic clinical trials – where the focus is on studying overall management strategies rather than specific interventions – there is likely to be higher quality evidence in support of conservative intervention for the majority of people

Conservative interventions considered here will include the most common treatments utilized in practice: (1) Joint Mobilization/Manipulation, (2) Exercise Interventions, (3) Patient Education, (4) Physical Modalities, (5) Cognitive-Behavioral Interventions, and (6) Traction. A description of each intervention and a summary of the evidence on effectiveness will follow.

Joint mobilization can be defined as: "a manual therapy technique comprising a continuum of passive movements to the joints and/or related soft tissues that are applied at various speeds and amplitudes, **including a small amplitude, high velocity therapeutic movement**" (APTA, 1997). Joint mobilization encompasses manipulation since manipulation is generally considered specifically the small amplitude, high velocity movement imparted to a joint. Another way of expressing this is to distinguish between "Non-Thrust" and "Thrust" techniques, the former referring to mobilization and the latter manipulation.

Joint mobilization is utilized to treat primarily impairments of joint mobility, range of motion and pain. Many disciplines employ joint mobilization, including the professions of chiropractic, physical therapy, osteopathy and medicine. Manipulative therapy has been studied extensively and therefore a high volume of information can be found on the topic. There has been great interest in better understanding the mechanisms of action of manipulation, and in investigating the effectiveness of manipulation in treating back pain. The mechanisms of action of spine manipulation can be broadly divided into (1) mechanical and (2) non-mechanical effects. Although there have been many theories relative to the mechanical effects of manipulation over the years, recent evidence based upon more direct measurement of spine movement supports the conclusion that thrust techniques result in multi-axial intervertebral displacements. These displacements increase in association with the applied force and occur at multiple segmental levels (Keller TS et al, 2003). This suggests that a manipulative force will impact an entire spinal region as opposed to a specific segmental level. However it is common practice to apply the force to the most restricted segmental level, determined by joint mobility assessment findings. Non-mechanical effects of manipulation are thought to be related to altered pain processing, both at the peripheral and central nervous system levels. A Hypoalgesic effect has been found to occur immediately following joint manipulation (Bialosky JE et al 2008). Also of interest is the somewhat paradoxical effect of manipulation to either increase motorneuron firing, when it is desirable to facilitate deep segmental muscle activity for example, or decrease motorneuron firing when heightened muscle activity is unwanted (Colloca CJ et al, 2006). Numerous clinical trials have been conducted investigating the effectiveness of manipulation for treating back pain. In a systematic review of non-pharmacologic

treatments.

with back disorders.

**4.1 Joint mobilization/manipulation** 

interventions for back pain, Chou suggests that manipulation, along with cognitive behavioral therapy, exercise and interdisciplinary rehabilitation, is moderately effective in reducing pain and improving function in people with acute or chronic back pain (Chou R , Huffman LH, 2007). A recent systematic review, however, concludes that spinal manipulation has a small effect on pain and function compared to other interventions, and that this difference is not clinically significant (Rubinstein SM et al, 2007).

A clinical prediction rule has been established to better predict which patients respond favorably to manipulation (Flynn T A, 2002). Predictors of success with manipulation can be found in table 4. The positive Likelihood Ratio (LR) for the presence of 4 or more patient characteristics is 24, indicating that when patients meet the criteria, they have a very good chance of responding positively to manipulation. This rule has undergone validation studies, which support the contention that when patients are placed in subgroups based upon their presenting signs/symptoms and exam findings, treatment can be better targeted to their condition and outcomes will improve (Childs et al, 2004).

It is worthy to note that all national clinical guidelines for low back pain address spinal manipulation, although the recommendations vary. The majority of countries recommend manipulation for the treatment of acute low back pain (Bigos S et al, 1994).


Table 4. Clinical Prediction Rule for Spinal Manipulation

Spinal manipulation is a safe, conservative care option for the treatment of back pain. There are few contraindications, however: the presence of serious underling pathology, advanced osteoporosis, infection and cauda equina syndrome would be considered absolute contraindications to spinal manipulation. The mechanisms of action of manipulation are not fully understood, however currently it is believed that there are both mechanical and nonmechanical effects.

In general, manipulation has been found to have a small to moderate effect on decreasing pain and improving function in people with back pain. Most conservative care practitioners who perform spinal manipulation employ other types of interventions when treating back pain. Finally, clinical decision rules can be used to help identify which patients are likely to respond favorably to manipulation. Table 4 summarizes the patient characteristics that would predict success with a treatment program that includes spinal manipulation. The likelihood of the patient benefiting from manipulation increases in relation to the number of criteria met; if patients meet all or most criteria they have a high probability of improving with manipulation.

#### **4.2 Exercise**

Exercise interventions, along with patient education, are foundational in the conservative approach to treating musculoskeletal conditions of the spine. It is through exercise that body

Conservative Management of Low Back Pain 219

A clinical prediction rule has been developed to help identify back pain patients who are likely to respond favorably to spine stabilization exercise (Hicks GE et al, 2005). This clinical decision-making tool can be found in table 5. Relatively younger patients that demonstrate aberrant movements during active movement testing, who have a SLR of at least 91 degrees and who test positive on the prone instability test are more likely to benefit from spine

It appears that there is more support in the literature for exercise interventions in the chronic versus acute back pain population, however as the research community refines methodology in studying treatment for acute pain, there is promise that exercise will gain support in certain subgroups of patients. For example, there is evidence that on active movement testing, when patients demonstrate decreased symptoms with select trunk movements, prescribing exercise that is consistent with the directional preference improves

Of all interventions for back pain, exercise is the one most directly oriented to improving the structural integrity of the spine. For many people with back pain, not only can skilled movements help to control pain, but most importantly if performed regularly, they will

Educational interventions have always been an integral part of the conservative approach to treating musculoskeletal conditions. Patient education for back patients should address, among other things, the importance of maintaining an active life and avoidance of bed rest, activity modification, and prevention. There is evidence that empowering patients with knowledge of their condition and fostering a sense of self-efficacy improves health outcomes. It is especially important in the acute phase to emphasize the need to stay active

When addressing patient education, it is important to distinguish between acute injury and chronic pain. In acute injury states, patients should be instructed to control forces on the spine as a first measure. This may mean a short period of rest. Then the patient can begin an *active rest* phase, where they modify activities as needed to control pain but stay active and move

For people with chronic or chronic recurring back pain, it is important for the health care practitioner to evaluate the patent from a pain management perspective. This may include the utilization of scales to assess pain response, such as the *Fear-Avoidance Belief Questionnaire* and the *McGill Pain Questionnaire.* Elevated fear- avoidance beliefs have been associated with poorer health outcomes for musculoskeletal conditions, so it is important to

throughout the day. Following this phase, they can gradually return to normal activity.

include strategies to address these beliefs (Nicholas MK, George SZ, 2011).

stabilization exercise.

Patient Characteristics

Positive Prone Instability Test Aberrant movement observed Straight Leg Raise > 91 degrees

Table 5. Clinical Prediction Rule for Spine Stabilization Exercise

Age < 40 years

outcomes (Long A et al, 2004).

**4.3 Patient education** 

(Liddle SD, 2007).

maintain function and prevent re-occurrence.

tissues adapt to the stresses and demands of everyday living, and recover from injury. The majority of cases of back pain are mechanical in nature, and ultimately a functional approach will produce the greatest long-term benefit. Exercise also requires active participation on the part of the patient, and therefore helps to foster self-efficacy.

There are many types of exercise and exercise programs for the back. The terminology used to describe these types of exercise can be confusing, and there is overlap in their descriptors. Examples of exercise types include: strengthening, flexibility, endurance (aerobic), motor control, stabilization, corrective, posture retraining, and functional. It is important in analyzing research on the effectiveness of exercise to understand what type of exercise was employed in the study because exercise is not a single entity. Ideally, exercise is prescribed and specifically targeted to the patient's movement impairments. For example, there are a subset of people with back pain who may not demonstrate strength deficits, however they demonstrate faulty patterns of muscle recruitment in the performance of functional tasks. For these individuals, motor control exercises – which emphasize the correct execution of the movement – will best address the patient problem.

In addition to specific categories of exercise, several exercise programs exist which are directed at treating low back pain. For example, William's flexion exercises were developed in the 1930's and consist of a series of exercises designed to improve the strength and flexibility of the trunk and pelvic girdle. These exercises favor flexion-based spinal movements. Later, The McKenzie approach to treating back pain was developed and the "extension principle" was established (McKenzie RA, 1981). This principle is in turn based upon the general concept of *directional preference*, whereby the prescription of exercise is dependant upon the patient's symptomatic response with specific trunk movements. The McKenzie approach is inclusive of the diagnostic procedures used to determine the type of mechanical problem causing the patient's symptoms. Interpretation of the many clinical trials conducted relative to the efficacy of the McKenzie system (Machedo LAC, 2006). Other more general exercise programs, those designed for the general population, have been incorporated into conservative management strategies; examples of these programs include yoga (Chou R, 2007) and Pilates.

There have been numerous clinical trials investigating the effectiveness of exercise in the treatment of back pain. A randomized control trial involving patients who had undergone microdiscectomy compared the effectiveness of lumbar stabilization exercise to general exercise and to no exercise. The lumbar stabilization subgroup demonstrated the most significant improvement in pain and function (Yilmaz A et al, 2003). Koumantakis also found that lumbar stabilization was effective in decreasing pain and improving function in people with non-specific low back pain (Koumantakis GA, 2005). In another systematic review, Ferreira found that spine stabilization exercise has a modest benefit for people with spine pain. Generally, outcomes of treatment are better with spine stabilization compared to no treatment, "usual care", and patient education. Further, spine stabilization is more effective in treating chronic pain than acute pain, although it does help prevent recidivism after acute pain episodes (Ferreira PH, 2006). In a systematic review of clinical trials that involved subjects with various stages of back pain, acute, subacute and chronic, Hayden found exercise to be effective in reducing pain in people with chronic pain . A particular approach to exercise, graded activity, was found to result in fewer absences from work in people with subacute pain. For the acute population, exercise was as effective as other conservative interventions in treating back pain (Hayden JA et al, 2005).

tissues adapt to the stresses and demands of everyday living, and recover from injury. The majority of cases of back pain are mechanical in nature, and ultimately a functional approach will produce the greatest long-term benefit. Exercise also requires active

There are many types of exercise and exercise programs for the back. The terminology used to describe these types of exercise can be confusing, and there is overlap in their descriptors. Examples of exercise types include: strengthening, flexibility, endurance (aerobic), motor control, stabilization, corrective, posture retraining, and functional. It is important in analyzing research on the effectiveness of exercise to understand what type of exercise was employed in the study because exercise is not a single entity. Ideally, exercise is prescribed and specifically targeted to the patient's movement impairments. For example, there are a subset of people with back pain who may not demonstrate strength deficits, however they demonstrate faulty patterns of muscle recruitment in the performance of functional tasks. For these individuals, motor control exercises – which emphasize the correct execution of

In addition to specific categories of exercise, several exercise programs exist which are directed at treating low back pain. For example, William's flexion exercises were developed in the 1930's and consist of a series of exercises designed to improve the strength and flexibility of the trunk and pelvic girdle. These exercises favor flexion-based spinal movements. Later, The McKenzie approach to treating back pain was developed and the "extension principle" was established (McKenzie RA, 1981). This principle is in turn based upon the general concept of *directional preference*, whereby the prescription of exercise is dependant upon the patient's symptomatic response with specific trunk movements. The McKenzie approach is inclusive of the diagnostic procedures used to determine the type of mechanical problem causing the patient's symptoms. Interpretation of the many clinical trials conducted relative to the efficacy of the McKenzie system (Machedo LAC, 2006). Other more general exercise programs, those designed for the general population, have been incorporated into conservative management strategies; examples of these programs include

There have been numerous clinical trials investigating the effectiveness of exercise in the treatment of back pain. A randomized control trial involving patients who had undergone microdiscectomy compared the effectiveness of lumbar stabilization exercise to general exercise and to no exercise. The lumbar stabilization subgroup demonstrated the most significant improvement in pain and function (Yilmaz A et al, 2003). Koumantakis also found that lumbar stabilization was effective in decreasing pain and improving function in people with non-specific low back pain (Koumantakis GA, 2005). In another systematic review, Ferreira found that spine stabilization exercise has a modest benefit for people with spine pain. Generally, outcomes of treatment are better with spine stabilization compared to no treatment, "usual care", and patient education. Further, spine stabilization is more effective in treating chronic pain than acute pain, although it does help prevent recidivism after acute pain episodes (Ferreira PH, 2006). In a systematic review of clinical trials that involved subjects with various stages of back pain, acute, subacute and chronic, Hayden found exercise to be effective in reducing pain in people with chronic pain . A particular approach to exercise, graded activity, was found to result in fewer absences from work in people with subacute pain. For the acute population, exercise was as effective as other

conservative interventions in treating back pain (Hayden JA et al, 2005).

participation on the part of the patient, and therefore helps to foster self-efficacy.

the movement – will best address the patient problem.

yoga (Chou R, 2007) and Pilates.

A clinical prediction rule has been developed to help identify back pain patients who are likely to respond favorably to spine stabilization exercise (Hicks GE et al, 2005). This clinical decision-making tool can be found in table 5. Relatively younger patients that demonstrate aberrant movements during active movement testing, who have a SLR of at least 91 degrees and who test positive on the prone instability test are more likely to benefit from spine stabilization exercise.


Table 5. Clinical Prediction Rule for Spine Stabilization Exercise

It appears that there is more support in the literature for exercise interventions in the chronic versus acute back pain population, however as the research community refines methodology in studying treatment for acute pain, there is promise that exercise will gain support in certain subgroups of patients. For example, there is evidence that on active movement testing, when patients demonstrate decreased symptoms with select trunk movements, prescribing exercise that is consistent with the directional preference improves outcomes (Long A et al, 2004).

Of all interventions for back pain, exercise is the one most directly oriented to improving the structural integrity of the spine. For many people with back pain, not only can skilled movements help to control pain, but most importantly if performed regularly, they will maintain function and prevent re-occurrence.

#### **4.3 Patient education**

Educational interventions have always been an integral part of the conservative approach to treating musculoskeletal conditions. Patient education for back patients should address, among other things, the importance of maintaining an active life and avoidance of bed rest, activity modification, and prevention. There is evidence that empowering patients with knowledge of their condition and fostering a sense of self-efficacy improves health outcomes. It is especially important in the acute phase to emphasize the need to stay active (Liddle SD, 2007).

When addressing patient education, it is important to distinguish between acute injury and chronic pain. In acute injury states, patients should be instructed to control forces on the spine as a first measure. This may mean a short period of rest. Then the patient can begin an *active rest* phase, where they modify activities as needed to control pain but stay active and move throughout the day. Following this phase, they can gradually return to normal activity.

For people with chronic or chronic recurring back pain, it is important for the health care practitioner to evaluate the patent from a pain management perspective. This may include the utilization of scales to assess pain response, such as the *Fear-Avoidance Belief Questionnaire* and the *McGill Pain Questionnaire.* Elevated fear- avoidance beliefs have been associated with poorer health outcomes for musculoskeletal conditions, so it is important to include strategies to address these beliefs (Nicholas MK, George SZ, 2011).

Conservative Management of Low Back Pain 221

population in recognition of the strong role that patient's beliefs, thought processes and behaviors have on their experience of back pain. A patient's cognition interacts with their movement system and can influence the level of disability and the intensity of the pain experience (Nicholas MK, George SZ, 2011). The physical therapist is in a good position to help modify patient's belief systems to enhance functional recovery due to the relatively

A list of common strategies used in conservative management of musculoskeletal condition

Cognitive behavioral interventions have been found to be effective in decreasing pain and improving function in patients with low back pain - either alone or in combination with active exercise. (Smeets RJ, 2006). In a systematic review of behavioral interventions for chronic low back pain, the authors found moderate-level evidence in support of behavioral

It is likely that cognitive-behavioral interventions will become more integrated into conservative back pain management as knowledge of the role of psychosocial factors in the pain experience increases. Identification of yellow flags in back pain patients helps the healthcare provider select patients most likely to benefit from a cognitive behavioral approach. Likewise, recognition of yellow flags in the acute pain population has the

There is almost no treatment for back pain that can claim greater longevity than traction. However, despite this long history and the many innovative ways that have been developed to apply traction forces to the spine, there is little evidence to support its use in practice. A systematic review based upon an analysis of 25 randomized controlled trials involving traction concludes: "the results of the available studies involving mixed groups of acute, sub-acute and chronic patients with LBP with and without sciatica were quite consistent, indicating that continuous or intermittent traction as a single treatment for LBP is not likely

There is some evidence that a subgroup of patients, those that experience leg pain, signs of nerve root compression and either perpheralization of symptoms with trunk extension movements or display a positive well leg raise have better outcomes with traction. In addition, a clinical prediction rule has been developed that can help identify patients that are more likely to respond favorably to tractions: (1) FABQ score < 21, (2) absence of neurological signs,

(3) age > 30 years, and (4) does not perform manual labor (Cai C et al, 2009).

long relationship physical therapists develop with their patients.

Advice on staying active/Avoidance of bed rest

Emphasis on back pain as a common human experience

Table 7. Cognitive-behavioral strategies utilized in the treatment of back pain

Pain mechanisms & pain control

Activity modification/ Joint protection

interventions for short-term pain control (Henschke N et al, 2011).

Risk factors for chronic pain

potential to prevent future episodes of back pain.

effective for this group" (Clarke JA et al, 2010).

Promote self-efficacy Role of anxiety and stress

can be found in table 7.

**4.6 Traction** 

Individual education appears to be most effective, although it is not clear what mode of education is best (Engers AJ, 2008). In a large prospective controlled trial, patients that were given an educational pamphlet in a medical care setting demonstrated decrease pain and improved satisfaction with care compared to patients that did not receive the educational intervention (Coudeyre E et al, 2007). A simple back booklet has been developed that deemphasizes back pain as a medical problem and promotes self-efficacy. When tested in a randomized controlled trial, investigators found that for back pain patients with elevated fear-avoidance beliefs, there was a significant improvement in self-report disability scores compared to a control group who were given a more traditional educational intervention (Burton AK et al, 1999).


Table 6. Components of patient education for people with back pain

Patient education should be part of a comprehensive program of care for people with back pain. This needs to be considered when analyzing the research on patient education. As with other conservative interventions, the impact of patient education on pain and function is small to moderate. However, the costs associated with patient education are relatively low and therefore worth the time investment for the patient and health care provider.

#### **4.4 Physical modalities**

The role of physical agents in the treatment of low back pain is primarily for pain control and to aid in the healing response in the presence of acute injury. The most common physical modalities are: heat, cold, ultrasound and electrotherapy (including TENS). Although many clinical guidelines for low back pain do not recommend passive therapies, this is generally due to the small effect size of individual physical modalities on improving outcomes for people with back pain (Bigos S et al, 1994). This is especially true for chronic pain. In acute pain, the use of heat has relatively stronger support than the other modalities (Chou R, 2007). In contemporary practice, modalities are used in conjunction with active therapies. When patients present with acute back pain that impacts their quality of life and interferes with their ability to function, early pain control can speed recovery. There is evidence that the inclusion of physical agents to standard treatment approaches has added benefit and improves treatment outcomes (Hurwitz EL et al, 2002).

#### **4.5 Cognitive behavioral interventions**

Cognitive behavioral therapy has long been used in the mental health arena to treat a variety of psychological conditions such as anxiety disorders and depression. This psychotherapeutic approach is structured, requires a step-by-step progression, and is timeintensive. The cognitive-behavioral approach has also been found to benefit people with back pain. Cognitive-behavioral strategies have been applied especially to the chronic pain

Individual education appears to be most effective, although it is not clear what mode of education is best (Engers AJ, 2008). In a large prospective controlled trial, patients that were given an educational pamphlet in a medical care setting demonstrated decrease pain and improved satisfaction with care compared to patients that did not receive the educational intervention (Coudeyre E et al, 2007). A simple back booklet has been developed that deemphasizes back pain as a medical problem and promotes self-efficacy. When tested in a randomized controlled trial, investigators found that for back pain patients with elevated fear-avoidance beliefs, there was a significant improvement in self-report disability scores compared to a control group who were given a more traditional educational intervention

(Burton AK et al, 1999).

**4.4 Physical modalities** 

Patient Education for Back Pain Pain mechanisms & pain control

Risk factors for chronic pain

Promote self-efficacy Role of anxiety and stress

Activity modification/ Joint protection

Advice on staying active/Avoidance of bed rest

Table 6. Components of patient education for people with back pain

benefit and improves treatment outcomes (Hurwitz EL et al, 2002).

**4.5 Cognitive behavioral interventions** 

Emphasis on back pain as a common human experience

and therefore worth the time investment for the patient and health care provider.

Patient education should be part of a comprehensive program of care for people with back pain. This needs to be considered when analyzing the research on patient education. As with other conservative interventions, the impact of patient education on pain and function is small to moderate. However, the costs associated with patient education are relatively low

The role of physical agents in the treatment of low back pain is primarily for pain control and to aid in the healing response in the presence of acute injury. The most common physical modalities are: heat, cold, ultrasound and electrotherapy (including TENS). Although many clinical guidelines for low back pain do not recommend passive therapies, this is generally due to the small effect size of individual physical modalities on improving outcomes for people with back pain (Bigos S et al, 1994). This is especially true for chronic pain. In acute pain, the use of heat has relatively stronger support than the other modalities (Chou R, 2007). In contemporary practice, modalities are used in conjunction with active therapies. When patients present with acute back pain that impacts their quality of life and interferes with their ability to function, early pain control can speed recovery. There is evidence that the inclusion of physical agents to standard treatment approaches has added

Cognitive behavioral therapy has long been used in the mental health arena to treat a variety of psychological conditions such as anxiety disorders and depression. This psychotherapeutic approach is structured, requires a step-by-step progression, and is timeintensive. The cognitive-behavioral approach has also been found to benefit people with back pain. Cognitive-behavioral strategies have been applied especially to the chronic pain population in recognition of the strong role that patient's beliefs, thought processes and behaviors have on their experience of back pain. A patient's cognition interacts with their movement system and can influence the level of disability and the intensity of the pain experience (Nicholas MK, George SZ, 2011). The physical therapist is in a good position to help modify patient's belief systems to enhance functional recovery due to the relatively long relationship physical therapists develop with their patients.

 A list of common strategies used in conservative management of musculoskeletal condition can be found in table 7.


Table 7. Cognitive-behavioral strategies utilized in the treatment of back pain

Cognitive behavioral interventions have been found to be effective in decreasing pain and improving function in patients with low back pain - either alone or in combination with active exercise. (Smeets RJ, 2006). In a systematic review of behavioral interventions for chronic low back pain, the authors found moderate-level evidence in support of behavioral interventions for short-term pain control (Henschke N et al, 2011).

It is likely that cognitive-behavioral interventions will become more integrated into conservative back pain management as knowledge of the role of psychosocial factors in the pain experience increases. Identification of yellow flags in back pain patients helps the healthcare provider select patients most likely to benefit from a cognitive behavioral approach. Likewise, recognition of yellow flags in the acute pain population has the potential to prevent future episodes of back pain.

#### **4.6 Traction**

There is almost no treatment for back pain that can claim greater longevity than traction. However, despite this long history and the many innovative ways that have been developed to apply traction forces to the spine, there is little evidence to support its use in practice. A systematic review based upon an analysis of 25 randomized controlled trials involving traction concludes: "the results of the available studies involving mixed groups of acute, sub-acute and chronic patients with LBP with and without sciatica were quite consistent, indicating that continuous or intermittent traction as a single treatment for LBP is not likely effective for this group" (Clarke JA et al, 2010).

There is some evidence that a subgroup of patients, those that experience leg pain, signs of nerve root compression and either perpheralization of symptoms with trunk extension movements or display a positive well leg raise have better outcomes with traction. In addition, a clinical prediction rule has been developed that can help identify patients that are more likely to respond favorably to tractions: (1) FABQ score < 21, (2) absence of neurological signs, (3) age > 30 years, and (4) does not perform manual labor (Cai C et al, 2009).

Conservative Management of Low Back Pain 223

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#### **5. Conclusion**

The conservative approach to treating back pain encompasses all elements of patient management from the initial examination, through the diagnostic process and finally to the prescription of the most appropriate interventions. It is based upon principles that are now well supported in the literature, including selection of the least invasive treatments that can be supported by the current scientific evidence, the orientation toward helping patients help themselves, and utilizing an active program of care. These principles reflect a biopsychosocial model of healthcare, where the experience of pain is viewed as a multifaceted phenomenon. The best hope for reversing the trends toward ever more costly care for back pain is to focus treatment on the underlying factors that contribute to it, and to encourage people to take responsibility for their health.

#### **6. References**


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Publication No. 95-0642; December, 1994.

2011; 11: 585-598.

*Spine J.* 2009; 18: 554-561.

*Intern Med.* 2004; 141: 920-928.

*JOSPT.* 2008; 38 (9): A1-A34.

**5. Conclusion** 

**6. References** 


**10** 

 *Nigeria* 

**Therapeutic Exercises in the** 

Johnson Olubusola Esther

*Department of Medical Rehabilitation, Obafemi Awolowo University, Ile-Ife,* 

**Management of Non-Specific Low Back Pain** 

Low back pain (LBP) is neither a disease nor a diagnostic entity of any sort (Ehrlich, 2003). It is a common problem which affects the majority of adults at least once in a life time. It is irksome, of global concern, as common as headache affecting all age groups and races (May, 2001; Hazard, et al, 1996). It is a prevalent musculoskeletal condition, and a common cause of disability especially in its chronic/recurrent state. The majority of LBP episodes resolve spontaneously while a significant minority becomes recurrent and a small percentage remain persistent (Dunn and Croft, 2004). LBP has a point prevalence of about 7 to 33% and lifetime prevalence of nearly 85% (Walker, 2000). Frank et al, (1996); Vollin, (1997) reported

Management of LBP is costly; accounting for a large and increasing proportion of health care expenditures without evidence of corresponding improvements in outcomes (Martin et al, 2008). Frymoyer, (1988) reported that the major costs of LBP can be identified with the chronic and recurrent LBP. Low back pain occurs in a wide variety of medical, musculoskeletal, and neurologic conditions (Roach et al, 1997, Cypress, 1983). Most individuals reporting at the clinic for management of excruciating LBP have experienced pain in the low back many times before the episode that brings them to the hospital. Low back pain accounts for serious job absenteeism in industrialized societies, a case that would have been similar in most parts of Africa except that there is hardly any financial

Low back pain was defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica) (Omokhodion et al, 2002), and as "pain limited to the region between the lower margins of the 12th rib and the glutei folds" with or without leg pain (sciatica) (Manek and Macgregor, 2005). It is specifically an aggregation of symptoms of pain/discomfort originating from the lumbar spine apparatus with or without radiation of pain to the gluteal fold and legs. It is regarded as a symptom from impairments in the structures in the low back which originates e.g. from muscles, ligaments, intervertebral disc. Low back pain is a symptom of myriads of causes ranging from mechanical causes; accounting for about 90% of cases and non-mechanical causes i.e. secondary to an underlying pathology in the rest of the population. It is a symptom which appears in the clinic as a disease entity because it is highly reported. It can be primary i.e.

similarly that it affects about 70-85% of individuals once in their lifetime.

compensation for sick leave, hence less report of LBP in clinics.

**1. Introduction** 


### **Therapeutic Exercises in the Management of Non-Specific Low Back Pain**

#### Johnson Olubusola Esther

*Department of Medical Rehabilitation, Obafemi Awolowo University, Ile-Ife, Nigeria* 

#### **1. Introduction**

224 Low Back Pain

Machedo LAC, Souza MS, Ferreira PH, Ferreira FML. The McKenzie method for low back

Magee DJ. Orthopedic Physical Assessment. 4th ed. W.B. Saunders Co: Philadelphia, PA:

Martin BI, Deyo RA, Marza SK et al. Expenditures and health status among adults with back

Nguyen TH, Randolph DC, Talmage J, et al. Long-term Outcomes of Lumbar Fusion Among

Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an

Riddle DL. Classification and low back pain: a review of the literature and critical analysis of

Rubinstein SM, van Middlekoop M, Assendelft WJJ, de Boer MR et al. Spinal manipulative

Saur PM, Ensink FB, Frese K, et al. Lumbar range of motion: reliability and validity of the

Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance

Stausberg J, Lehmann N, Kaczmarek D et al. Reliability of diagnosis coding in ICD-10. *Int J* 

Smeets RJ, Vlaeyen JW, Hidding A et al. Active rehabilitation for chronic low back pain: cognitive-behavioral, physical or both? *BMC Musculoskeletal Disord.* 2006: 7:5. Spoto MM, Collins J. Physiotherapy diagnosis in clinical practice: a survey of orthopedic certified specialists in the USA. *Physiotherapy Research International.* 2008; 13: 31-41. Stanton TR,Fritz JM, Hancock MJ et al. Evaluation of a treatment-based classification algorithm for low back pain: a cross-sectional study. *Phys Ther.* 2011; 91: 496-509. UK BEAM Trial Team. United Kingdom back pan exercise and manipulation (UK BEAM)

Vlanin M. Psychometric properties and clinical usefulness of the Oswestry Disability Index.

Weinstein JN, Tosteson TD, Lurie JD et al. Surgical versus non-operative treatment for

World Health Organization. *International Classification of Disease.* ICD-10. Geneva,

World Health Organization: *International Classification of Functioning, Disability and Health:* 

Yilmaz, A. Yilmaz, F. Merdol, D. et al: Efficacy of dynamic lumbar stabilization exercise in

lumbar microdiscectomy*. The Internet Journal of Minimally Invasive Spinal Technology.* 

*Journal of Chiropractic Medicine.* 2008; 7 (4): 161-163.

lumbar disk herniation. *JAMA.* 2006;296 (20): 2441-2450.

*ICF.* Geneva, Switzerland: World Health Organization; 2008.

Issue 2. Art No: CD008112. DOI: 10.1002/14651858.CD008112.pub2. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, Inc.,

Workers' Compensation : A Historical Cohort Study. Spine. 2011(Feb 15);36(4) :320-331.

therapy for chronic low-back Pain. *Cochrane Database of Systematic Reviews.* 2011,

inclinometer technique in the clinical measurement of trunk flexibility. *Spine.* 1996;

imaging appearance of the lumbar spine and low back pain, age and occupation in

randomized trial: effectiveness of physical treatments for back pain in primary care.

McKenzie RA. *The Lumbar Spine.* Spinal Publications; Waikanae, New Zealand, 1981.

and neck problems. *JAMA.*2008; 299 (6): 656-664.

update for physical therapists. *Pain.* 2011. 91 (5): 765-776.

selected systems. Physical Therapy. 1998; 78 (7):708-737.

2006; 31 (9): E254-E262.

St. Louis, MO: 2002.

males. *Eur Spine J.* 1997; 6: 106-114.

*Med Inform.* 2008; 77: 50-7.

*BMJ.* 2004; 329; 1377.

Switzerland: 2005.

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21:1332-1338.

2002.

pain: a systematic review of the literature with a meta-analysis approach. *Spine.* 

Low back pain (LBP) is neither a disease nor a diagnostic entity of any sort (Ehrlich, 2003). It is a common problem which affects the majority of adults at least once in a life time. It is irksome, of global concern, as common as headache affecting all age groups and races (May, 2001; Hazard, et al, 1996). It is a prevalent musculoskeletal condition, and a common cause of disability especially in its chronic/recurrent state. The majority of LBP episodes resolve spontaneously while a significant minority becomes recurrent and a small percentage remain persistent (Dunn and Croft, 2004). LBP has a point prevalence of about 7 to 33% and lifetime prevalence of nearly 85% (Walker, 2000). Frank et al, (1996); Vollin, (1997) reported similarly that it affects about 70-85% of individuals once in their lifetime.

Management of LBP is costly; accounting for a large and increasing proportion of health care expenditures without evidence of corresponding improvements in outcomes (Martin et al, 2008). Frymoyer, (1988) reported that the major costs of LBP can be identified with the chronic and recurrent LBP. Low back pain occurs in a wide variety of medical, musculoskeletal, and neurologic conditions (Roach et al, 1997, Cypress, 1983). Most individuals reporting at the clinic for management of excruciating LBP have experienced pain in the low back many times before the episode that brings them to the hospital. Low back pain accounts for serious job absenteeism in industrialized societies, a case that would have been similar in most parts of Africa except that there is hardly any financial compensation for sick leave, hence less report of LBP in clinics.

Low back pain was defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica) (Omokhodion et al, 2002), and as "pain limited to the region between the lower margins of the 12th rib and the glutei folds" with or without leg pain (sciatica) (Manek and Macgregor, 2005). It is specifically an aggregation of symptoms of pain/discomfort originating from the lumbar spine apparatus with or without radiation of pain to the gluteal fold and legs. It is regarded as a symptom from impairments in the structures in the low back which originates e.g. from muscles, ligaments, intervertebral disc. Low back pain is a symptom of myriads of causes ranging from mechanical causes; accounting for about 90% of cases and non-mechanical causes i.e. secondary to an underlying pathology in the rest of the population. It is a symptom which appears in the clinic as a disease entity because it is highly reported. It can be primary i.e.

Physical Therapy in the Management of Non-Specific Low Back Pain 227

stress on the spine. His treatment has been criticized over the years as being non specific with massive tractive force. Maitland distinguished between mobilization and manipulation and puts emphasizes on mobilization where oscillatory movements are performed on a chosen joint and within the available range of movement within the limit of the patient's tolerance, mobilization was better accepted as being milder and easy to learn. Nwuga in 1976 worked on integrating the thoughts of these authors with some innovations of his own and came up with his own vertical and transverse oscillatory pressure. He came up with the Nwugarian institute for back pain management in 1996 to promote the training of Nigerian physiotherapists in the art and science of manipulative therapy (Nwuga, 2007). His technique is popularly employed by physiotherapists in Nigeria in treating low back pain. The concept of spinal stability was introduced in medical research in 1970 (Barr et al, 2005). It was theorized that back injury and therefore pain could be caused by the gradual degeneration of joints and soft tissue over time from repetitive microtrauma, which was caused by poor control of spinal structures (Farfan, 1975). This theory has evolved and conclusions are that spinal stability is a dynamic process that includes both static positions and controlled movement which includes both an alignment in sustained postures (Figure 1) and movement patterns that reduce tissue strain, trauma to the joints or soft tissue, and allows for efficient muscle action (Sahrmann, 2002). It was also theorized that movement patterns that were altered by faulty strength and flexibility, fatigue from poor endurance, or abnormal neural control would eventually cause tissue damage. Tissue damage would lead to decreased stability of spinal structures, increased challenges to the already inefficient

muscles, and the perpetuation of a degenerative cascade (Magee, 2002).

Fig. 1. Pelvic Stabilization in Sitting Positions (da Siva et al, 2009)

mechanical/non-specific and also secondary with an underlying pathology i.e. nonmechanical. Non-specific LBP appears to be commoner affecting mostly individuals between ages 30 and 50years; in children and adolescents however, LBP appears to be usually secondary to an underlying pathology.

#### **2. Classification**

Low back pain can be acute, sub-acute or long-term; acute-on-chronic, with recurrence rearing its head among a significant minority. Acute low back pain is usually defined as the duration of an episode of low back pain persisting for less than 6 weeks; sub-acute as LBP which lasts between 6 and 12 weeks and long-term LBP as persisting for 12 weeks or more; chronic LBP is defined as LBP persisting for 12 weeks or more. Recurrent low back pain is defined as a new episode after a symptom-free period of 6 months, but not an exacerbation of chronic low back pain (van Tulder et al, 2004). Walker, 2000 estimated that 70-95% of any adult population will suffer at least one episode of back pain in its lifetime, while Truchon, 2001 proposed 60-80%. Fifty per cent of such cases will recur within 3 months (Lawrence et al, 2006). Recurrent and chronic LBP accounts for more than 70% of cases reported at clinics. Acute LBP is a common presentation of back pain and it is usually self-limiting; lasting less than 3 months and may not need any medical intervention. About half of those individuals who experience acute LBP will have recurrences within the first year of the first episode, leading to a possible history of chronic low back pain (Moffroid, 1997). Waddell and Bry-Jones (1994) submitted that LBP not settled within 8–12 weeks is likely to result in chronic disabling pain.

Acute LBP tends towards becoming a complex chronic pain disorder, involving anatomical, physiological, psychological and social aspects (Roach et al, 1997). Chronic/recurrent LBP is a chief source of incapacitation, suffering and expense frequently resulting in significant worry and interference with daily activities leading to significant level of disability. It is a tremendous burden on patients and health service providers. It usually results from acute pain of muscular or connective tissue origin, which persists in approximately 30% of cases in adults and 20% of cases in adolescents.

#### **3. Schools of thought**

There are several schools of thoughts regarding the management of LBP that have thrived through decades of physiotherapy practice, ranging from the crude methods of tying a patient to a ladder and dropping him, James Mennell, Cyriax and Kaltenborn schools of thoughts, the William's flexion exercise, Richardson and other researchers spinal stabilization theory and McKenzie's standardized basis of classification of LBP with its extension and flexion protocols of treatment. Other schools of thought include Nwuga's vertical and transverse oscillatory manouevres of treatment of disc lesion, also Alexander and Mulligan's technique of management of LBP. James Mennell pointed at the facet joints, postural strain, and adhesions as causative factors in back pain. He proposed treating low back pain with manipulations designed to restore joint play in joints for the relief of pain and restoration of normal voluntary movement and functions (Nwuga, 2007). In 1933 Mixter and Bar reported that the intervertebral disc as a major factor in back pain with or without sciatica. James Cyriax also agreed with this school of thought and identified two types of disc lesion, viz: nuclear protrusion and annular protrusion. He applied a rotational torsion

mechanical/non-specific and also secondary with an underlying pathology i.e. nonmechanical. Non-specific LBP appears to be commoner affecting mostly individuals between ages 30 and 50years; in children and adolescents however, LBP appears to be

Low back pain can be acute, sub-acute or long-term; acute-on-chronic, with recurrence rearing its head among a significant minority. Acute low back pain is usually defined as the duration of an episode of low back pain persisting for less than 6 weeks; sub-acute as LBP which lasts between 6 and 12 weeks and long-term LBP as persisting for 12 weeks or more; chronic LBP is defined as LBP persisting for 12 weeks or more. Recurrent low back pain is defined as a new episode after a symptom-free period of 6 months, but not an exacerbation of chronic low back pain (van Tulder et al, 2004). Walker, 2000 estimated that 70-95% of any adult population will suffer at least one episode of back pain in its lifetime, while Truchon, 2001 proposed 60-80%. Fifty per cent of such cases will recur within 3 months (Lawrence et al, 2006). Recurrent and chronic LBP accounts for more than 70% of cases reported at clinics. Acute LBP is a common presentation of back pain and it is usually self-limiting; lasting less than 3 months and may not need any medical intervention. About half of those individuals who experience acute LBP will have recurrences within the first year of the first episode, leading to a possible history of chronic low back pain (Moffroid, 1997). Waddell and Bry-Jones (1994) submitted that LBP not settled within 8–12 weeks is likely to result in chronic

Acute LBP tends towards becoming a complex chronic pain disorder, involving anatomical, physiological, psychological and social aspects (Roach et al, 1997). Chronic/recurrent LBP is a chief source of incapacitation, suffering and expense frequently resulting in significant worry and interference with daily activities leading to significant level of disability. It is a tremendous burden on patients and health service providers. It usually results from acute pain of muscular or connective tissue origin, which persists in approximately 30% of cases in

There are several schools of thoughts regarding the management of LBP that have thrived through decades of physiotherapy practice, ranging from the crude methods of tying a patient to a ladder and dropping him, James Mennell, Cyriax and Kaltenborn schools of thoughts, the William's flexion exercise, Richardson and other researchers spinal stabilization theory and McKenzie's standardized basis of classification of LBP with its extension and flexion protocols of treatment. Other schools of thought include Nwuga's vertical and transverse oscillatory manouevres of treatment of disc lesion, also Alexander and Mulligan's technique of management of LBP. James Mennell pointed at the facet joints, postural strain, and adhesions as causative factors in back pain. He proposed treating low back pain with manipulations designed to restore joint play in joints for the relief of pain and restoration of normal voluntary movement and functions (Nwuga, 2007). In 1933 Mixter and Bar reported that the intervertebral disc as a major factor in back pain with or without sciatica. James Cyriax also agreed with this school of thought and identified two types of disc lesion, viz: nuclear protrusion and annular protrusion. He applied a rotational torsion

usually secondary to an underlying pathology.

**2. Classification** 

disabling pain.

adults and 20% of cases in adolescents.

**3. Schools of thought** 

stress on the spine. His treatment has been criticized over the years as being non specific with massive tractive force. Maitland distinguished between mobilization and manipulation and puts emphasizes on mobilization where oscillatory movements are performed on a chosen joint and within the available range of movement within the limit of the patient's tolerance, mobilization was better accepted as being milder and easy to learn. Nwuga in 1976 worked on integrating the thoughts of these authors with some innovations of his own and came up with his own vertical and transverse oscillatory pressure. He came up with the Nwugarian institute for back pain management in 1996 to promote the training of Nigerian physiotherapists in the art and science of manipulative therapy (Nwuga, 2007). His technique is popularly employed by physiotherapists in Nigeria in treating low back pain.

The concept of spinal stability was introduced in medical research in 1970 (Barr et al, 2005). It was theorized that back injury and therefore pain could be caused by the gradual degeneration of joints and soft tissue over time from repetitive microtrauma, which was caused by poor control of spinal structures (Farfan, 1975). This theory has evolved and conclusions are that spinal stability is a dynamic process that includes both static positions and controlled movement which includes both an alignment in sustained postures (Figure 1) and movement patterns that reduce tissue strain, trauma to the joints or soft tissue, and allows for efficient muscle action (Sahrmann, 2002). It was also theorized that movement patterns that were altered by faulty strength and flexibility, fatigue from poor endurance, or abnormal neural control would eventually cause tissue damage. Tissue damage would lead to decreased stability of spinal structures, increased challenges to the already inefficient muscles, and the perpetuation of a degenerative cascade (Magee, 2002).

Fig. 1. Pelvic Stabilization in Sitting Positions (da Siva et al, 2009)

Physical Therapy in the Management of Non-Specific Low Back Pain 229

Fig. 3. Anatomy of transversus abdominis. The attachments of tranversus abdominis to the lumbar vertebrae via middle ananterior layers of the thoracolumbar fascia are not shown. Todemonstrate the bilaminar fascial attachment of the posterior layer of the thoracolumbar fascia it is shown connecting only to the spinous processes. LR ± lateral raphe, LA ± linae alba, SP ± superficial lamina of the posterior layer of the thoracolumbar fasica, DP ± deep

McKenzie purported the use of repeated movements and sustained positions in the examination and treatment of low back disorders (The McKenzie Institute, 2001). McKenzie subsequently classified mechanical LBP into three syndromes; postural, dysfunction and derangement syndromes (McKenzie, 1981). Patients with postural syndrome are individuals who have intermittent episodes of pain believed to be the result of prolonged stress on soft tissues (bad posture) around the lumbar spine. They have full range of movements, no deformity and they are treated with postural advice (McKenzie, 1981; Porter, 1993). Patients with dysfunctional syndrome are individuals who are believed to have had trauma or a postural problem producing adaptive shortening of the soft tissues. Pain is triggered by over use, posture is poor, movement in the spine is restricted and there is pain at the end-range (McKenzie, 1981; Porter, 1993). Patients with derangement syndrome of the intervertebral disc may be with or without kyphotic or scoliotic deformity. There are two types of derangement, posterior derangement D1 to D6 and anterior derangement D7. Treatment for these derangements is usually to move the individual to D1 where they can manage themselves (McKenzie, 1981; Porter, 1993). Pain is usually centralised, after which, patients can care for themselves with extension activity and maintain lumbar lordosis and subsequently obtain functional recovery (Mckenzie, 1981; Donelson et al, 1990; Porter, 1993). All these theories addressed the intervertebral disc and or the facet joint as probable sources

lamina of the posterior layer of the thoraco-lumbar fascia.

Source: Hodges, (1999)

The lumbar multifidi and abdominals especially the transversus abdominis have been implicated in LBP and in face of muscle deactivation subsequent to recovery from an episode of LBP. Furthermore evidences by Hides et al (1992, 2008) are in support of the positive role of the lumbar multifidus muscle in segmental stabilization of the lumbar spine. Barr et al, (2005) in their review on lumbar stabilization submitted that the multifidi and transversus abdominus muscles are major stabilizers of the spine. Biomechanical studies have also highlighted the role of the multifidus muscle in provision of segmental stiffness (Keifer and Shirazi, 1995; Wilke et al, 1995), control of the spinal segment's neutral zone (Panjabi et al, 1989; Panjabi 1992) and its capacity to stabilize the spine when spinal stability is challenged. It has been reported that within a day subsequent to the first episode of LBP, the lumbar multifidus muscle showed ipsilateral pain related decrease in muscle bulk and this loss of bulk is not recovered even after recovery from back pain (Hides et al, 1994, 1996).

Panjabi (1992) reported evidences of lumbar instability, low muscular strength and endurance among subjects with LBP. Instability according to him could be a result of tissue damage, making the segment more difficult to stabilize, low muscular strength or endurance, or poor muscular control; bone and ligaments: lumbar instability is usually a combination of all three. These three components are interdependent, and one system could compensate for deficits in another. The multifidi extend along the entire length of the spine and is much thicker at the low back and waist (Johnson, 2002), comprising superficial and deep fibers (Figure 2). The transverses abdominus is the chief abdominal stabilizer of the spine (Figure 3). The quadratus lumborum (Mc Gill, 2002), pelvic floor muscles (Sapsford and Hodges, 2001), internal and external oblique, rectus abdominus, iliopsoas and paraspinal muscles are other muscles that contribute to stability of the spine.

Fig. 2. Multifidus Muscles Source: coreconcepts.com.sg. Accessed 23rd December, 2011

The lumbar multifidi and abdominals especially the transversus abdominis have been implicated in LBP and in face of muscle deactivation subsequent to recovery from an episode of LBP. Furthermore evidences by Hides et al (1992, 2008) are in support of the positive role of the lumbar multifidus muscle in segmental stabilization of the lumbar spine. Barr et al, (2005) in their review on lumbar stabilization submitted that the multifidi and transversus abdominus muscles are major stabilizers of the spine. Biomechanical studies have also highlighted the role of the multifidus muscle in provision of segmental stiffness (Keifer and Shirazi, 1995; Wilke et al, 1995), control of the spinal segment's neutral zone (Panjabi et al, 1989; Panjabi 1992) and its capacity to stabilize the spine when spinal stability is challenged. It has been reported that within a day subsequent to the first episode of LBP, the lumbar multifidus muscle showed ipsilateral pain related decrease in muscle bulk and this loss of bulk is not recovered even after recovery from back pain (Hides et al, 1994, 1996). Panjabi (1992) reported evidences of lumbar instability, low muscular strength and endurance among subjects with LBP. Instability according to him could be a result of tissue damage, making the segment more difficult to stabilize, low muscular strength or endurance, or poor muscular control; bone and ligaments: lumbar instability is usually a combination of all three. These three components are interdependent, and one system could compensate for deficits in another. The multifidi extend along the entire length of the spine and is much thicker at the low back and waist (Johnson, 2002), comprising superficial and deep fibers (Figure 2). The transverses abdominus is the chief abdominal stabilizer of the spine (Figure 3). The quadratus lumborum (Mc Gill, 2002), pelvic floor muscles (Sapsford and Hodges, 2001), internal and external oblique, rectus abdominus, iliopsoas and

paraspinal muscles are other muscles that contribute to stability of the spine.

Fig. 2. Multifidus Muscles

Source: coreconcepts.com.sg. Accessed 23rd December, 2011

Fig. 3. Anatomy of transversus abdominis. The attachments of tranversus abdominis to the lumbar vertebrae via middle ananterior layers of the thoracolumbar fascia are not shown. Todemonstrate the bilaminar fascial attachment of the posterior layer of the thoracolumbar fascia it is shown connecting only to the spinous processes. LR ± lateral raphe, LA ± linae alba, SP ± superficial lamina of the posterior layer of the thoracolumbar fasica, DP ± deep lamina of the posterior layer of the thoraco-lumbar fascia. Source: Hodges, (1999)

McKenzie purported the use of repeated movements and sustained positions in the examination and treatment of low back disorders (The McKenzie Institute, 2001). McKenzie subsequently classified mechanical LBP into three syndromes; postural, dysfunction and derangement syndromes (McKenzie, 1981). Patients with postural syndrome are individuals who have intermittent episodes of pain believed to be the result of prolonged stress on soft tissues (bad posture) around the lumbar spine. They have full range of movements, no deformity and they are treated with postural advice (McKenzie, 1981; Porter, 1993). Patients with dysfunctional syndrome are individuals who are believed to have had trauma or a postural problem producing adaptive shortening of the soft tissues. Pain is triggered by over use, posture is poor, movement in the spine is restricted and there is pain at the end-range (McKenzie, 1981; Porter, 1993). Patients with derangement syndrome of the intervertebral disc may be with or without kyphotic or scoliotic deformity. There are two types of derangement, posterior derangement D1 to D6 and anterior derangement D7. Treatment for these derangements is usually to move the individual to D1 where they can manage themselves (McKenzie, 1981; Porter, 1993). Pain is usually centralised, after which, patients can care for themselves with extension activity and maintain lumbar lordosis and subsequently obtain functional recovery (Mckenzie, 1981; Donelson et al, 1990; Porter, 1993). All these theories addressed the intervertebral disc and or the facet joint as probable sources

2009).

**5. Exercise therapy** 

2000).

Physical Therapy in the Management of Non-Specific Low Back Pain 231

Efforts have hence been exerted to improve the efficacy of its treatment especially in its recurrent or chronic nature (Feurstain and Battie, 1995). Physiotherapy is probably the treatment most widely used for back complaints of mechanical origin especially in the subacute and chronic states. Spinal manipulation for patients who are failing to return to normal activities have however been suggested among patients with LBP (van Tulder et al,

Several approaches of management have been used in managing non-specific low back pain with varying degrees of success. Drugs have been widely accepted in managing acute LBP. Physiotherapy is central to the overall management of LBP in the sub-acute and chronic phases. Physiotherapy management of long term low back pain favours active low back treatment programmes involving improving aerobic fitness, increasing the strength and flexibility of the lumbar musculature and ensuring lumbar stability (Shiple, 1997). Physiotherapy modalities including cryotherapy, Transcutaneous Electrical Nerve Stimulation (TENS) and heat therapy, back care education, back school, biofeedback, and functional restoration are used as adjunct to physiotherapy regimens including massage, heat, traction, ultrasound, short wave diathermy, back care education. It also involves the use of physical agents and modalities in physiotherapy to manage LBP. These include rest using supports e.g lumbar corsets, heat therapy, cold therapy, spinal manipulation and electro analgesia (Low and Reed, 1994; Foster et al, 1999; Li and Bombardier, 2001; Gracey et al, 2002). These rehabilitative and physical treatments can be helpful and with the aim of combating relapse, however when LBP become complex, the psychological components become an important part of the treatment. Pain management programme/pain clinics are used in managing psychological aspect of pain. Work hardening is also introduced to

restore physical, behavioural and vocational functions facilitating return to work.

Several treatment strategies, for instance, joint mobilization and manipulation, soft tissue massage techniques, electrotherapy, acupuncture, and traction, are utilized in clinical practice to treat low back pain, with varying degrees of effectiveness. Exercises are commonly prescribed for LBP by physiotherapists, but only seem to be supported as an intervention by evidence for patients with chronic LBP further more conclusions from systematic reviews are that exercises are effective in managing chronic LBP Hayden, (2005); Liddle, (2004). Lewis et al, (2008) in their systematic review also reaffirmed that exercises were effective in reducing pain in people with CLBP. Most studies concluded that active exercises were a valuable therapeutic approach in managing LBP, despite the lack of consensus on the optimal exercise techniques, intensity or active intervention (Abenhaim,

Exercise therapy appears to be the most often-used physical therapy intervention in treating people with back pain (Nachemson, 1990). It aims at abolishing pain, restoring and maintaining full range of motion, improving the strength and endurance of lumbar and abdominal muscles, thereby contributing to early restoration of normal function (Nachemson, 1990; Brukner and Khan, 1993). Additionally mechanical support to the low back which helps to obtain recovery with minimal chance of relapse is provided. Exercise training are often used improve function in low back rehabilitation and to prevent

of problem in non-specific back pain. Mulligan (2004) however submitted a theory that incorporates the intervertebral discs and facet joints. He opined that facet joint mobility brings improvement in minor cases of LBP. He reported on sustained natural apophyseal glides (SNAGS) which are a combination of sustained facet glide with movement. This he reported improves mobility of the facet joint and simultaneously heals the intervertebral disc.

A large number of muscles cross the spine, and all contribute to the modulation of lumbar stability and movement to some extent. This is a complex system consisting of deep muscles that have their origin or insertion on the lumbar vertebrae, which theoretically are responsible for the control of stiffness and intervertebral relationships, and the global muscle system that encompasses the large superficial muscles of the trunk that are the torque generators for spinal motion and handle external loads applied to the spine (Bergmark, 1989; Barr et al, 2005). Weakness of abdominal and back muscles especially the back extensors, muscular dysfunction in the low back, and abdominal muscles, and poor joint flexibility in the back and hamstring are reported as precursors for LBP (Biering Sørenson, 1984, Pollock and Wilmore, 1990, Robinson, 1992, Richardson and Jull, 1995, McArdle et al, 1996,). Several tests have been developed to identify individuals with weak abdominal and leg muscles with the aim of preventing low back pain. Kraus Weber test of minimum fitness is a series of exercises that measure strength and flexibility of the back, abdominal, psoas and hamstring muscles, it was developed by Kraus and Hirschland in 1954 from their clinical experience that majority of back disorders could have been prevented by maintaining a certain level of fitness. Persons who could pass this test were considered to be unlikely candidates for developing low back problems (Safrit and Wood, 1995). The Kraus Weber test addressed strength and flexibility and not muscular endurance. Muscular endurance capabilities of back muscles may be as important as or even more important than strength in the prevention and treatment of low back pain. Moffroid (1997) submitted that lack of endurance of the trunk muscles is an important factor in LBP. Evidences are in literature linking weaknesses of abdominal and back extensor weakness with low back pain or and its susceptibility in, adults and children (Holmstrom et al, 1992, Mannion and Dolan, 1994, Luoto et al, 1995, Adegoke and Babatunde, 2007; Mbada and Ayanniyi, 2008; Johnson et al, 2009), and the Biering Sørenson's back muscles endurance tests of back pain susceptibility uphold this submission (Biering Sørenson, 1984). Biering Sørensen test of Static Muscular Endurance (BSME) is a simple clinical tool for the assessment of low back muscular endurance. It has been reported to be valid, reliable, safe, practical, responsive, easily administered and inexpensive (Alaranta, 2000; Udermann et al, 2003). The BSME either in its original version or as variants is believed to provide a global measure of back extension endurance capacity (Moreau et al, 2001).

#### **4. Management**

Low back pain is a costly quality of life-related health problem (Selkowitz, 2006), and its management has remained a formidable challenge in medical practice all over the world (Feurstain and Battie, 1995). It is also a complex multivariate problem that has been known to be resistant to simple solutions (The Back Letter, 2001) and its management has remained an unending task for health service providers especially because quite a sizeable proportion of the population will attend the clinic sometime in their lifetime complaining of LBP. Efforts have hence been exerted to improve the efficacy of its treatment especially in its recurrent or chronic nature (Feurstain and Battie, 1995). Physiotherapy is probably the treatment most widely used for back complaints of mechanical origin especially in the subacute and chronic states. Spinal manipulation for patients who are failing to return to normal activities have however been suggested among patients with LBP (van Tulder et al, 2009).

Several approaches of management have been used in managing non-specific low back pain with varying degrees of success. Drugs have been widely accepted in managing acute LBP. Physiotherapy is central to the overall management of LBP in the sub-acute and chronic phases. Physiotherapy management of long term low back pain favours active low back treatment programmes involving improving aerobic fitness, increasing the strength and flexibility of the lumbar musculature and ensuring lumbar stability (Shiple, 1997). Physiotherapy modalities including cryotherapy, Transcutaneous Electrical Nerve Stimulation (TENS) and heat therapy, back care education, back school, biofeedback, and functional restoration are used as adjunct to physiotherapy regimens including massage, heat, traction, ultrasound, short wave diathermy, back care education. It also involves the use of physical agents and modalities in physiotherapy to manage LBP. These include rest using supports e.g lumbar corsets, heat therapy, cold therapy, spinal manipulation and electro analgesia (Low and Reed, 1994; Foster et al, 1999; Li and Bombardier, 2001; Gracey et al, 2002). These rehabilitative and physical treatments can be helpful and with the aim of combating relapse, however when LBP become complex, the psychological components become an important part of the treatment. Pain management programme/pain clinics are used in managing psychological aspect of pain. Work hardening is also introduced to restore physical, behavioural and vocational functions facilitating return to work.

#### **5. Exercise therapy**

230 Low Back Pain

of problem in non-specific back pain. Mulligan (2004) however submitted a theory that incorporates the intervertebral discs and facet joints. He opined that facet joint mobility brings improvement in minor cases of LBP. He reported on sustained natural apophyseal glides (SNAGS) which are a combination of sustained facet glide with movement. This he reported improves mobility of the facet joint and simultaneously heals the intervertebral

A large number of muscles cross the spine, and all contribute to the modulation of lumbar stability and movement to some extent. This is a complex system consisting of deep muscles that have their origin or insertion on the lumbar vertebrae, which theoretically are responsible for the control of stiffness and intervertebral relationships, and the global muscle system that encompasses the large superficial muscles of the trunk that are the torque generators for spinal motion and handle external loads applied to the spine (Bergmark, 1989; Barr et al, 2005). Weakness of abdominal and back muscles especially the back extensors, muscular dysfunction in the low back, and abdominal muscles, and poor joint flexibility in the back and hamstring are reported as precursors for LBP (Biering Sørenson, 1984, Pollock and Wilmore, 1990, Robinson, 1992, Richardson and Jull, 1995, McArdle et al, 1996,). Several tests have been developed to identify individuals with weak abdominal and leg muscles with the aim of preventing low back pain. Kraus Weber test of minimum fitness is a series of exercises that measure strength and flexibility of the back, abdominal, psoas and hamstring muscles, it was developed by Kraus and Hirschland in 1954 from their clinical experience that majority of back disorders could have been prevented by maintaining a certain level of fitness. Persons who could pass this test were considered to be unlikely candidates for developing low back problems (Safrit and Wood, 1995). The Kraus Weber test addressed strength and flexibility and not muscular endurance. Muscular endurance capabilities of back muscles may be as important as or even more important than strength in the prevention and treatment of low back pain. Moffroid (1997) submitted that lack of endurance of the trunk muscles is an important factor in LBP. Evidences are in literature linking weaknesses of abdominal and back extensor weakness with low back pain or and its susceptibility in, adults and children (Holmstrom et al, 1992, Mannion and Dolan, 1994, Luoto et al, 1995, Adegoke and Babatunde, 2007; Mbada and Ayanniyi, 2008; Johnson et al, 2009), and the Biering Sørenson's back muscles endurance tests of back pain susceptibility uphold this submission (Biering Sørenson, 1984). Biering Sørensen test of Static Muscular Endurance (BSME) is a simple clinical tool for the assessment of low back muscular endurance. It has been reported to be valid, reliable, safe, practical, responsive, easily administered and inexpensive (Alaranta, 2000; Udermann et al, 2003). The BSME either in its original version or as variants is believed to provide a global

measure of back extension endurance capacity (Moreau et al, 2001).

Low back pain is a costly quality of life-related health problem (Selkowitz, 2006), and its management has remained a formidable challenge in medical practice all over the world (Feurstain and Battie, 1995). It is also a complex multivariate problem that has been known to be resistant to simple solutions (The Back Letter, 2001) and its management has remained an unending task for health service providers especially because quite a sizeable proportion of the population will attend the clinic sometime in their lifetime complaining of LBP.

**4. Management** 

disc.

Several treatment strategies, for instance, joint mobilization and manipulation, soft tissue massage techniques, electrotherapy, acupuncture, and traction, are utilized in clinical practice to treat low back pain, with varying degrees of effectiveness. Exercises are commonly prescribed for LBP by physiotherapists, but only seem to be supported as an intervention by evidence for patients with chronic LBP further more conclusions from systematic reviews are that exercises are effective in managing chronic LBP Hayden, (2005); Liddle, (2004). Lewis et al, (2008) in their systematic review also reaffirmed that exercises were effective in reducing pain in people with CLBP. Most studies concluded that active exercises were a valuable therapeutic approach in managing LBP, despite the lack of consensus on the optimal exercise techniques, intensity or active intervention (Abenhaim, 2000).

Exercise therapy appears to be the most often-used physical therapy intervention in treating people with back pain (Nachemson, 1990). It aims at abolishing pain, restoring and maintaining full range of motion, improving the strength and endurance of lumbar and abdominal muscles, thereby contributing to early restoration of normal function (Nachemson, 1990; Brukner and Khan, 1993). Additionally mechanical support to the low back which helps to obtain recovery with minimal chance of relapse is provided. Exercise training are often used improve function in low back rehabilitation and to prevent

Physical Therapy in the Management of Non-Specific Low Back Pain 233

training. Muscular or local endurance refers to the ability of an isolated muscle group to perform repeated contractions over a period to time (Kisner and Colby, 1996). This kind of endurance exercise is both rhythmical and repetitive in nature or static with resulting fatigue confined to the local group of muscles that is exercised (Wilmore, 1982). General or cardiovascular endurance is the ability to perform large dynamic exercise for long periods of time (Kisner and Colby, 1996). Muscular strength is to muscular endurance as development of the cardiovascular and respiratory system is to cardiovascular endurance (Wilmore, 1982). Endurance is mechanically defined as either the point of isometric fatigue, where the contraction can no longer be maintained at a certain level or as the point of dynamic fatigue, when repetitive work can no longer be sustained at a certain force level (Alaranta, 2000)

Endurance exercises incorporating the back extensors and the abdominal muscles have been proposed for use in the management of low back pain (Biering Sorenson, 1984; Foster and Fulton, 1991). This is possibly because individuals with greater levels of muscular strength and endurance and cardiovascular fitness tend to have fewer spinal problems (Cady et al, 1979; Mayer and Gatchel, 1988; and Nelson et al, 1995), and that trunk muscle endurance has been identified as a potential riskfactor for the development of back pain (Biering Sorensen, 1984). Chok et al (1999) reported that trunk endurance training reduced pain and improved function at 3 weeks after the onset of treatment in their study to evaluate the effectiveness of trunk extensor endurance training on pain and disability in subjects with sub-acute low back pain of 7 days – 7 weeks onset. Johannes et al (1995) compared the effects of intensive training of muscle endurance and a treatment protocol that emphasized coordination in the trunk and found that the two groups studied, improved in pain, disability and spinal mobility. Johnson et al (2010) compared the efficacy of McKenzie exercise, endurance training and endurance training and back care education and concluded that McKenzie exercise was effective in modulating long-term LBP and proposed that a combination therapy involving McKenzie exercise, endurance training with McKenzie exercise was more effective. Exercise training increases endorphins and alter perception of pain, perhaps by reducing anxiety and depression (Blumenthal et al, 1982). Identifying high or low muscular endurance has been reported to alert the patient and clinician to a need for possible

Figures 4-12: Low Back Core Stabilization Exercises; 4-9 level one exercises; 10-12, level two

Fig. 4. Pelvic tilt: Exercise for the core spinal stabilizer transversus abdominus muscle

modifications to the usual treatment regime (McIntosh et al, 1998).

exercises; Source: Dr. Douglas M.G. DC; http://www.chirogeek.com

deconditioning of lumbar musculature, to prevent persistent low-back pain (Chok et al, 1999; Shiple, 1997). Jackson and Brown (1983) opined that exercises will decrease pain, strengthen muscles, decrease mechanical stress to spinal structures, improve fitness level, prevent injury, and improve posture and mobility in patients with low back pain. The exercise modes used by physiotherapists managing LBP patients include aerobic exercise, range of motion and stretching exercises and strengthening exercises for the trunk musculature (Brukner and Khan, 1993). Also balance training for better trunk and abdominal control, stabilization exercise and endurance exercises (Biering Sorenson, 1984; Foster and Fulton, 1991; Panjabi, 1992). In a study by Franca et al (2010) segmental stabilization and strengthening exercises effectively reduced pain and functional disability in individuals with chronic low back pain. Additionally segmental stabilization further improved transversus abdominus muscle activation capacity.

The role of exercise in back pain transcends all the phases of medical or health management namely preventive, curative and rehabilitative phases. It is probably the cheapest physiotherapeutic intervention and which gives the patient some measure of direct control over her treatment (Brukner and Khan, 1993). Exercise and movements cause alternate compression and relaxation of the articular cartilage, and ensure the movement of the synovial fluid into the articular cartilage as the area of pressure changes over the surface (Twomey, 1992). This allows for good health and optimal functioning of the articular cartilage. It also results in thicker, stronger ligaments that maintain their compliance and flexibility and that also become stronger at the bone-ligament-bone complex. The nutrition and health of the intervertebral discs is equally enhanced by exercises. Exercise also reduces the risk of developing osteoarthritis and osteoarthritic changes have been shown to begin only in areas where collagen is not often stressed by movement and pressure (Twomey, 1992). Exercises are done as mainstay of treatment to improve trunk stabilization. Exercises which results in proper muscle function will compensate for structural damages in spinal structure (Barr et al, 2005); nevertheless the deficits that have been defined in lumbar stabilization in patients with LBP seem to be mostly related to muscular and neurologic function.

Bone and muscle are both dynamic structures that respond positively to exercises and adversely to disuse (Mernard and Stanish, 1991). A strong inverse relationship exists between muscle mass and osteoporosis such that a decline in muscle mass is matched by an increasing fragility of bone. However the loss of muscle mass due to disuse can be substantially reversed by exercise training programme (Shepard, 1988, Menard and Stanish, 1991). It has hence been suggested that physiotherapists have the responsibility to include exercise as an essential part of prophylaxis and treatment in addition to other more passive treatment modalities such as massage, mobilization, manipulation and traction (Twomey, 1992).

Endurance of the back muscles is associated with LBP (Nourbakhsh and Arab, 2002). Endurance can be defined as the ability to perform prolonged bouts of work without experiencing much fatigue or exhaustion (Wilmore, 1982). It was similarly defined as the ability of a muscle to contract repeatedly or generate tension, sustain that tension, and resist fatigue over a prolong period of time (Delateur, 1982). It is probably the most underrated component of the total physical training program and is comprised of two different components (Wilmore, 1982) and is more important than strength in low back muscles

deconditioning of lumbar musculature, to prevent persistent low-back pain (Chok et al, 1999; Shiple, 1997). Jackson and Brown (1983) opined that exercises will decrease pain, strengthen muscles, decrease mechanical stress to spinal structures, improve fitness level, prevent injury, and improve posture and mobility in patients with low back pain. The exercise modes used by physiotherapists managing LBP patients include aerobic exercise, range of motion and stretching exercises and strengthening exercises for the trunk musculature (Brukner and Khan, 1993). Also balance training for better trunk and abdominal control, stabilization exercise and endurance exercises (Biering Sorenson, 1984; Foster and Fulton, 1991; Panjabi, 1992). In a study by Franca et al (2010) segmental stabilization and strengthening exercises effectively reduced pain and functional disability in individuals with chronic low back pain. Additionally segmental stabilization further

The role of exercise in back pain transcends all the phases of medical or health management namely preventive, curative and rehabilitative phases. It is probably the cheapest physiotherapeutic intervention and which gives the patient some measure of direct control over her treatment (Brukner and Khan, 1993). Exercise and movements cause alternate compression and relaxation of the articular cartilage, and ensure the movement of the synovial fluid into the articular cartilage as the area of pressure changes over the surface (Twomey, 1992). This allows for good health and optimal functioning of the articular cartilage. It also results in thicker, stronger ligaments that maintain their compliance and flexibility and that also become stronger at the bone-ligament-bone complex. The nutrition and health of the intervertebral discs is equally enhanced by exercises. Exercise also reduces the risk of developing osteoarthritis and osteoarthritic changes have been shown to begin only in areas where collagen is not often stressed by movement and pressure (Twomey, 1992). Exercises are done as mainstay of treatment to improve trunk stabilization. Exercises which results in proper muscle function will compensate for structural damages in spinal structure (Barr et al, 2005); nevertheless the deficits that have been defined in lumbar stabilization in patients with LBP seem to be mostly related to muscular and neurologic

Bone and muscle are both dynamic structures that respond positively to exercises and adversely to disuse (Mernard and Stanish, 1991). A strong inverse relationship exists between muscle mass and osteoporosis such that a decline in muscle mass is matched by an increasing fragility of bone. However the loss of muscle mass due to disuse can be substantially reversed by exercise training programme (Shepard, 1988, Menard and Stanish, 1991). It has hence been suggested that physiotherapists have the responsibility to include exercise as an essential part of prophylaxis and treatment in addition to other more passive treatment modalities such as massage, mobilization, manipulation and traction (Twomey,

Endurance of the back muscles is associated with LBP (Nourbakhsh and Arab, 2002). Endurance can be defined as the ability to perform prolonged bouts of work without experiencing much fatigue or exhaustion (Wilmore, 1982). It was similarly defined as the ability of a muscle to contract repeatedly or generate tension, sustain that tension, and resist fatigue over a prolong period of time (Delateur, 1982). It is probably the most underrated component of the total physical training program and is comprised of two different components (Wilmore, 1982) and is more important than strength in low back muscles

improved transversus abdominus muscle activation capacity.

function.

1992).

training. Muscular or local endurance refers to the ability of an isolated muscle group to perform repeated contractions over a period to time (Kisner and Colby, 1996). This kind of endurance exercise is both rhythmical and repetitive in nature or static with resulting fatigue confined to the local group of muscles that is exercised (Wilmore, 1982). General or cardiovascular endurance is the ability to perform large dynamic exercise for long periods of time (Kisner and Colby, 1996). Muscular strength is to muscular endurance as development of the cardiovascular and respiratory system is to cardiovascular endurance (Wilmore, 1982). Endurance is mechanically defined as either the point of isometric fatigue, where the contraction can no longer be maintained at a certain level or as the point of dynamic fatigue, when repetitive work can no longer be sustained at a certain force level (Alaranta, 2000)

Endurance exercises incorporating the back extensors and the abdominal muscles have been proposed for use in the management of low back pain (Biering Sorenson, 1984; Foster and Fulton, 1991). This is possibly because individuals with greater levels of muscular strength and endurance and cardiovascular fitness tend to have fewer spinal problems (Cady et al, 1979; Mayer and Gatchel, 1988; and Nelson et al, 1995), and that trunk muscle endurance has been identified as a potential riskfactor for the development of back pain (Biering Sorensen, 1984).

Chok et al (1999) reported that trunk endurance training reduced pain and improved function at 3 weeks after the onset of treatment in their study to evaluate the effectiveness of trunk extensor endurance training on pain and disability in subjects with sub-acute low back pain of 7 days – 7 weeks onset. Johannes et al (1995) compared the effects of intensive training of muscle endurance and a treatment protocol that emphasized coordination in the trunk and found that the two groups studied, improved in pain, disability and spinal mobility. Johnson et al (2010) compared the efficacy of McKenzie exercise, endurance training and endurance training and back care education and concluded that McKenzie exercise was effective in modulating long-term LBP and proposed that a combination therapy involving McKenzie exercise, endurance training with McKenzie exercise was more effective. Exercise training increases endorphins and alter perception of pain, perhaps by reducing anxiety and depression (Blumenthal et al, 1982). Identifying high or low muscular endurance has been reported to alert the patient and clinician to a need for possible modifications to the usual treatment regime (McIntosh et al, 1998).

Figures 4-12: Low Back Core Stabilization Exercises; 4-9 level one exercises; 10-12, level two exercises; Source: Dr. Douglas M.G. DC; http://www.chirogeek.com

Fig. 4. Pelvic tilt: Exercise for the core spinal stabilizer transversus abdominus muscle

Physical Therapy in the Management of Non-Specific Low Back Pain 235

Fig. 9. Prone alternate arm and leg extension

Fig. 10. Supine heel drag to extended arms

Fig. 11. Supine sit-up

Fig. 12. Ball hyperextension

Fig. 5. Supine leg drag to the chest

Fig. 6. Supine lying alternate arm and leg

Fig. 7. Prone leg extension

Fig. 8. Prone single arm extension

Fig. 9. Prone alternate arm and leg extension

Fig. 5. Supine leg drag to the chest

Fig. 6. Supine lying alternate arm and leg

Fig. 7. Prone leg extension

Fig. 8. Prone single arm extension

Fig. 10. Supine heel drag to extended arms

Fig. 11. Supine sit-up

Fig. 12. Ball hyperextension

Physical Therapy in the Management of Non-Specific Low Back Pain 237

reducing work absence, functional disability, and kinesiophobia, and more workers in this group scored a higher perceived recovery during the 6-month follow-up. Akinpelu and Odebiyi (2004) determined the effect of a Nigerian back school model on some Nigerian industrial workers' knowledge of low back pain and back care and reported that the subjects' mean knowledge score increased significantly immediately and at 8 weeks after back school model administration. The authors therefore concluded that the back school model was effective in improving the workers' knowledge of LBP and back care. Also reports of Cochrane back reviewers (Heymans et al, 2004; Heymans et al, 2005) and a meta analysis (Maier and Harter, 2001) on the efficacy of back school versus sham diathermy and placebo was that back school was superior to sham diathermy and placebo for short term recovery and return to work and not for pain or long term recurrences. Authors have generally submitted that back school should be integrated into the other effective means of management e.g exercises. Daltroy et al (1997) designed an educational program modeled after several well-known back schools to reduce low back injuries among 4000 postal workers and observed increased knowledge among experimental unit workers, but no significant improvements in behaviours associated with back health or in proportion of

An essential of physical therapy management is the education of patients with low back pain on appropriate musculoskeletal structures, functions and the basic pathology of the patient's problem, and lifestyle adaptation that may be necessary to prevent recurrence of LBP (Twomey, 1992). Teaching is necessary and professionally desirable as the active role of the physiotherapist in the management of back pain and other conditions (Sotosky, 1984). The five educational elements commonly used in physical therapy sessions are- teaching, provision of information about illness, instructions for home exercises, giving advice, information and counselling about stress related problems (Sluijis, 1991). Patients in back care programmes are made to understand age changes and their effects on the spine and the spine's vulnerability to stress under particular loading conditions. They are then given instructions on home exercises for back and advised on the best postures for activities in

Behavioral and cognitive behavioral, inpatient and outpatient multidisciplinary pain clinics are usually considered to be the last resort as a treatment option. This course of treatment usually is offered late in the course of chronic LBP, typically after the patient has adopted a disability lifestyle automated by refractory operant influences. True behavioral modification is most effectively accomplished in an inpatient setting, where all aspects of the patient's waking and sleeping activities can be structured and controlled. The cost of hospitalization and interdisciplinary services in this venue must be weighed against other economic factors, such as those related to further medical or surgical care, loss of productivity, and compensated disability (Wheeler, 2007). Cognitive-behavioral pain treatment programs are usually combined with a functional rehabilitation approach and prove to be a successful treatment for many (Wheeler, 2007). There are few studies on the use of pain clinics in the

workers with tired backs.

**6. Back care education** 

standing, sitting and even lying positions (Twomey, 1992).

**7. Pain clinics in the management of LBP** 

#### a. Manipulative Therapy

The application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health is referred to as manipulation. It may be performed as a part of other therapies or whole medical systems, including chiropractic, massage, and naturopathy. It is a broad term encompassing massage, passive and active assisted range of motion and joint distraction or traction (Farell and Jensen, 1992). It was earlier proposed that manipulative therapy works by reducing subluxations, correcting vertebral mal-alignment, adjusting nuclear prolapse or tearing joint adhesion. However, evidence from studies reviewed by Twomey (1992) suggested a mechanism in which 'gapping' or separation of the joint surfaces by manipulation or movement would allow a piece of firm articular cartilage, caught between the articular surfaces the of the zygoapophyseal joint, blocking movements thereby returning the facet joint to its normal position. Studies have shown that spinal manipulation provides mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments (US DHHS, 2009). In a 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options to consider using when back pain does not improve with self-care. Spinal manipulation appears to provide relief from LBP at least over the short term (i.e., up to 3 months), and such effects may continue for up to 1 year. Nevertheless evidences in research are still under way to determine whether the effects of spinal manipulation depend on the duration and frequency of treatment.

Spinal manipulations are contra indicated in pateients with herniated discs resulting in or worsening cauda equina syndrome. Side effects of spinal manipulations minor discomfort in the treated area, headache, or tiredness. These effects usually go away in 1 to 2 days (US DHHS, 2009).

#### b. Back school

Back schools are health education programmes on back pain. Many back schools have been developed for different populations since 1969 when the first one was developed in sweden by Zachrison-forsell (Zachrison-forsell, 1980). The term "back school" implies providing information about the anatomy and function of the spine as well as advice on activities regarding prevention and self-treatment (Dihta, 1999); the teaching is carried out in group sessions. It is common to include instruction and practical guidance for exercise during back school sessions. The back school usually lasts approximately 4-6 hours. Often, the theoretical instruction is an integrated element of a comprehensive course of back rehabilitation, which also includes exercise programs. The integrated rehabilitation program is usually of 15-30 hours duration, spread over weeks to months (Dihta, 1999). Back school programs are usually led by physiotherapists, ergo therapists and relaxation therapists. The philosophy of the traditional back school was guided by "be careful" messages, such as; sit correctly, lift correctly, avoid forward bending, and so forth. In a modern back school the emphasis is to avoid fear, and the philosophy is to "ignore the pain as much as possible". This change in attitude has resulted in improved preventive results (Dihta, 1999).

A study compared high- and low-intensity back schools with usual care in occupational health care in Netherland, among workers sick-listed because of sub acute nonspecific low back pain (Heyman et al, 2006). The low-intensity back school was most effective in reducing work absence, functional disability, and kinesiophobia, and more workers in this group scored a higher perceived recovery during the 6-month follow-up. Akinpelu and Odebiyi (2004) determined the effect of a Nigerian back school model on some Nigerian industrial workers' knowledge of low back pain and back care and reported that the subjects' mean knowledge score increased significantly immediately and at 8 weeks after back school model administration. The authors therefore concluded that the back school model was effective in improving the workers' knowledge of LBP and back care. Also reports of Cochrane back reviewers (Heymans et al, 2004; Heymans et al, 2005) and a meta analysis (Maier and Harter, 2001) on the efficacy of back school versus sham diathermy and placebo was that back school was superior to sham diathermy and placebo for short term recovery and return to work and not for pain or long term recurrences. Authors have generally submitted that back school should be integrated into the other effective means of management e.g exercises. Daltroy et al (1997) designed an educational program modeled after several well-known back schools to reduce low back injuries among 4000 postal workers and observed increased knowledge among experimental unit workers, but no significant improvements in behaviours associated with back health or in proportion of workers with tired backs.

#### **6. Back care education**

236 Low Back Pain

The application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health is referred to as manipulation. It may be performed as a part of other therapies or whole medical systems, including chiropractic, massage, and naturopathy. It is a broad term encompassing massage, passive and active assisted range of motion and joint distraction or traction (Farell and Jensen, 1992). It was earlier proposed that manipulative therapy works by reducing subluxations, correcting vertebral mal-alignment, adjusting nuclear prolapse or tearing joint adhesion. However, evidence from studies reviewed by Twomey (1992) suggested a mechanism in which 'gapping' or separation of the joint surfaces by manipulation or movement would allow a piece of firm articular cartilage, caught between the articular surfaces the of the zygoapophyseal joint, blocking movements thereby returning the facet joint to its normal position. Studies have shown that spinal manipulation provides mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments (US DHHS, 2009). In a 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options to consider using when back pain does not improve with self-care. Spinal manipulation appears to provide relief from LBP at least over the short term (i.e., up to 3 months), and such effects may continue for up to 1 year. Nevertheless evidences in research are still under way to determine whether the effects of

spinal manipulation depend on the duration and frequency of treatment.

attitude has resulted in improved preventive results (Dihta, 1999).

Spinal manipulations are contra indicated in pateients with herniated discs resulting in or worsening cauda equina syndrome. Side effects of spinal manipulations minor discomfort in the treated area, headache, or tiredness. These effects usually go away in 1 to 2 days (US

Back schools are health education programmes on back pain. Many back schools have been developed for different populations since 1969 when the first one was developed in sweden by Zachrison-forsell (Zachrison-forsell, 1980). The term "back school" implies providing information about the anatomy and function of the spine as well as advice on activities regarding prevention and self-treatment (Dihta, 1999); the teaching is carried out in group sessions. It is common to include instruction and practical guidance for exercise during back school sessions. The back school usually lasts approximately 4-6 hours. Often, the theoretical instruction is an integrated element of a comprehensive course of back rehabilitation, which also includes exercise programs. The integrated rehabilitation program is usually of 15-30 hours duration, spread over weeks to months (Dihta, 1999). Back school programs are usually led by physiotherapists, ergo therapists and relaxation therapists. The philosophy of the traditional back school was guided by "be careful" messages, such as; sit correctly, lift correctly, avoid forward bending, and so forth. In a modern back school the emphasis is to avoid fear, and the philosophy is to "ignore the pain as much as possible". This change in

A study compared high- and low-intensity back schools with usual care in occupational health care in Netherland, among workers sick-listed because of sub acute nonspecific low back pain (Heyman et al, 2006). The low-intensity back school was most effective in

a. Manipulative Therapy

DHHS, 2009). b. Back school An essential of physical therapy management is the education of patients with low back pain on appropriate musculoskeletal structures, functions and the basic pathology of the patient's problem, and lifestyle adaptation that may be necessary to prevent recurrence of LBP (Twomey, 1992). Teaching is necessary and professionally desirable as the active role of the physiotherapist in the management of back pain and other conditions (Sotosky, 1984). The five educational elements commonly used in physical therapy sessions are- teaching, provision of information about illness, instructions for home exercises, giving advice, information and counselling about stress related problems (Sluijis, 1991). Patients in back care programmes are made to understand age changes and their effects on the spine and the spine's vulnerability to stress under particular loading conditions. They are then given instructions on home exercises for back and advised on the best postures for activities in standing, sitting and even lying positions (Twomey, 1992).

#### **7. Pain clinics in the management of LBP**

Behavioral and cognitive behavioral, inpatient and outpatient multidisciplinary pain clinics are usually considered to be the last resort as a treatment option. This course of treatment usually is offered late in the course of chronic LBP, typically after the patient has adopted a disability lifestyle automated by refractory operant influences. True behavioral modification is most effectively accomplished in an inpatient setting, where all aspects of the patient's waking and sleeping activities can be structured and controlled. The cost of hospitalization and interdisciplinary services in this venue must be weighed against other economic factors, such as those related to further medical or surgical care, loss of productivity, and compensated disability (Wheeler, 2007). Cognitive-behavioral pain treatment programs are usually combined with a functional rehabilitation approach and prove to be a successful treatment for many (Wheeler, 2007). There are few studies on the use of pain clinics in the

Physical Therapy in the Management of Non-Specific Low Back Pain 239

Researchers have used exercises of various types in the management of LBP with varying degrees of successes but not many studies have been able to rate one exercise protocol over another in the management of chronic LBP and not so much is in place as to which exercise is favourable at either the sub-acute or chronic stages. Combination physiotherapy regimens involving exercise of different types, back care education, specific schools of thoughts have also been used in managing low back pain and authors have reported better clinical improvement with combination of regimens focusing not just on the disc or facet joint for pain modulation but also on muscles reconditioning and patient education. Psychosocial component of management must be in focus in chronic/long-term cases, although not much has been documented in this regard. Waddell and Watson (2004) reviewed rehabilitation interventions for LBP, analysed within a biopsychosocial framework to test the hypothesis that effective rehabilitation interventions should have all three biological, psychological and social elements to address all of the potential obstacles to recovery. They concluded that virtually all the interventions included some form of exercise or physical activity element aimed at addressing the biological problem and restore physical function. However, this physical element alone was insufficient to achieve return to work. Most successful interventions also addressed beliefs in one way or another, and many of them included some kind of occupational intervention (work hardening). Most of the programmes that did not explicitly address these latter two elements were unsuccessful in achieving return to work. This evidence appears to support the hypothesis that a rehabilitation intervention is more likely to produce successful vocational outcomes if it addresses all three bio-psychosocial elements of disability and obstacles to recovery in chronic/long term LBP. Back care education on the other hand has is accepted as an important adjunct to other physiotherapy procedures in the management of low back pain and not necessarily as solely an effective means of managing LBP (Daltroy et al, 1997; Lønn et al, 1999), and evidences supporting back school as sole treatment modality are weak. Endurance exercise however has been reported to be effective in preventing chronic/long-term LBP but has not been investigated in many randomized controlled trials. Optimal functioning of the muscle system is desirable to control and protect the spinal segments following injury. Despite initial resolution of painful symptoms, failure to protect spinal segments could increase the likelihood of a recurrence of symptoms. Specific exercise training targeting the back and abdominal muscles including the multifidus and transversus abdominus muscles have been shown to

decrease pain and disability in chronic low back pain patients.

in children and adolescents.

McKenzie's classification is a standardized approach of assessing LBP as it identifies a directional preference for spinal movement which can form basis for classification in treating LBP. When this approach like any other mobilization is used in combination with rehabilitation of the abdominal; and back muscles, much better outcomes may be realized in combating LBP, especially when it is sub-acute, chronic/long-term. Treatment should be individualized, and where group treatment is considered, classification should form the basis of grouping. Group exercise will improve patient interaction and participation which may further ensure better and more specified outcomes and forestall recurrence. Prevention strategies should be introduced early in life, hence more studies to look into low back pain

**8. Conclusion** 

management of LBP, however Adam-Wilkey et al (2008) controlled trial compared outcomes in perception of pain and disability for a group of patients suffering with chronic LBP when managed in a hospital by either a regional pain clinic or a chiropractor and reported that reduction in mean pain intensity at the end of the study was 1.8 points greater for the chiropractic group than for the pain-clinic group.

I compared nineteen studies on effects of different physiotherapy regimens in the management of sub-acute and chronic mechanical LBP under the following headings viz: sample size, age and type of LBP, sampling technique and treatment methods which included duration of study, methods of treatment, and outcomes of the studies from 1985 to 2010. Two of the studies were done in the eighties, five in the nineties and nine in years two thousand and three till two thousand and ten. Sample sizes for the study were between thirty and two hundred and sixty. Most of the studies however involved approximately sixty individuals. Only one study, Petersen et al (2002) involved 148 subjects. Six of the studies were randomised clinical trials, quite a number assigned subjects into the groups randomly and four did not specify what they did. Subjects' age range fell between eighteen and seventy years. Although this is quite a wide range, most studies involved individuals from eighteen years to about forty to fifty five years. Only Risch et al (1993) involved an age range of twenty two to seventy years but a couple of other studies simply referred to their populations as adult populations. Most of the studies reviewed involved individuals with chronic LBP but , Chok et al, (1999), Petersen et al (2002) and Akosile et al (2006) involved individuals with , sub-acute, or both sub-acute and chronic LBP. Hides et al (2001) studied only individuals with acute LBP.

The least duration of any of these studies was 4 weeks; most of them took between 6-8 weeks and others above 8 weeks even up to 3 months. The vast array of the treatment methods had physiotherapy in form of exercises of different types including trunk muscle strengthening and endurance, McKenzie exercises, low impact aerobic exercise, spine stabilization. A study by (Nwuga and Nwuga, 1985), compared William's flexion exercise and McKenzie exercise and Akosile (2006) involved spine manipulation. Johnson et al, (2010) administered a combination treatment involving, McKenzie exercise, endurance training and back care education. Most studies incorporated back care education as baseline treatment and sometimes for comparison. Only four studies incorporated heat therapy in the management and only one study (Hides et al, 2001) involved medical management and this was the only study that involved subjects with acute LBP. It can be observed from these studies that most protocols of exercise were effective in the management of chronic LBP. The methods were not effective when it was either placebo or back care education solely or massage plus thermotherapy of some sort. These were however incorporated in some of the exercise protocols and the protocols were effective in the management of LBP. The only instance when exercise was not solely effective was in the study involving acute LBP (Hides et al, 2001). In this instance medical management was more effective in modulating acute LBP and stabilization exercise prevented recurrence of the LBP in the same study. Hides et al (2001) concluded that biomechanical research may explain why it is important to focus on particular muscles for their stabilizing functions in rehabilitation (Hides et al 2001). Franca et al (2010) reported superiority of segmental stabilization over strengthening exercise in combating muscle deactivation subsequent to episode of LBP. Muscle deactivation due to an episode of LBP has been implicated for recurrence of LBP.

#### **8. Conclusion**

238 Low Back Pain

management of LBP, however Adam-Wilkey et al (2008) controlled trial compared outcomes in perception of pain and disability for a group of patients suffering with chronic LBP when managed in a hospital by either a regional pain clinic or a chiropractor and reported that reduction in mean pain intensity at the end of the study was 1.8 points greater for the

I compared nineteen studies on effects of different physiotherapy regimens in the management of sub-acute and chronic mechanical LBP under the following headings viz: sample size, age and type of LBP, sampling technique and treatment methods which included duration of study, methods of treatment, and outcomes of the studies from 1985 to 2010. Two of the studies were done in the eighties, five in the nineties and nine in years two thousand and three till two thousand and ten. Sample sizes for the study were between thirty and two hundred and sixty. Most of the studies however involved approximately sixty individuals. Only one study, Petersen et al (2002) involved 148 subjects. Six of the studies were randomised clinical trials, quite a number assigned subjects into the groups randomly and four did not specify what they did. Subjects' age range fell between eighteen and seventy years. Although this is quite a wide range, most studies involved individuals from eighteen years to about forty to fifty five years. Only Risch et al (1993) involved an age range of twenty two to seventy years but a couple of other studies simply referred to their populations as adult populations. Most of the studies reviewed involved individuals with chronic LBP but , Chok et al, (1999), Petersen et al (2002) and Akosile et al (2006) involved individuals with , sub-acute, or both sub-acute and chronic LBP. Hides et al (2001) studied

The least duration of any of these studies was 4 weeks; most of them took between 6-8 weeks and others above 8 weeks even up to 3 months. The vast array of the treatment methods had physiotherapy in form of exercises of different types including trunk muscle strengthening and endurance, McKenzie exercises, low impact aerobic exercise, spine stabilization. A study by (Nwuga and Nwuga, 1985), compared William's flexion exercise and McKenzie exercise and Akosile (2006) involved spine manipulation. Johnson et al, (2010) administered a combination treatment involving, McKenzie exercise, endurance training and back care education. Most studies incorporated back care education as baseline treatment and sometimes for comparison. Only four studies incorporated heat therapy in the management and only one study (Hides et al, 2001) involved medical management and this was the only study that involved subjects with acute LBP. It can be observed from these studies that most protocols of exercise were effective in the management of chronic LBP. The methods were not effective when it was either placebo or back care education solely or massage plus thermotherapy of some sort. These were however incorporated in some of the exercise protocols and the protocols were effective in the management of LBP. The only instance when exercise was not solely effective was in the study involving acute LBP (Hides et al, 2001). In this instance medical management was more effective in modulating acute LBP and stabilization exercise prevented recurrence of the LBP in the same study. Hides et al (2001) concluded that biomechanical research may explain why it is important to focus on particular muscles for their stabilizing functions in rehabilitation (Hides et al 2001). Franca et al (2010) reported superiority of segmental stabilization over strengthening exercise in combating muscle deactivation subsequent to episode of LBP. Muscle deactivation due to an

chiropractic group than for the pain-clinic group.

only individuals with acute LBP.

episode of LBP has been implicated for recurrence of LBP.

Researchers have used exercises of various types in the management of LBP with varying degrees of successes but not many studies have been able to rate one exercise protocol over another in the management of chronic LBP and not so much is in place as to which exercise is favourable at either the sub-acute or chronic stages. Combination physiotherapy regimens involving exercise of different types, back care education, specific schools of thoughts have also been used in managing low back pain and authors have reported better clinical improvement with combination of regimens focusing not just on the disc or facet joint for pain modulation but also on muscles reconditioning and patient education. Psychosocial component of management must be in focus in chronic/long-term cases, although not much has been documented in this regard. Waddell and Watson (2004) reviewed rehabilitation interventions for LBP, analysed within a biopsychosocial framework to test the hypothesis that effective rehabilitation interventions should have all three biological, psychological and social elements to address all of the potential obstacles to recovery. They concluded that virtually all the interventions included some form of exercise or physical activity element aimed at addressing the biological problem and restore physical function. However, this physical element alone was insufficient to achieve return to work. Most successful interventions also addressed beliefs in one way or another, and many of them included some kind of occupational intervention (work hardening). Most of the programmes that did not explicitly address these latter two elements were unsuccessful in achieving return to work. This evidence appears to support the hypothesis that a rehabilitation intervention is more likely to produce successful vocational outcomes if it addresses all three bio-psychosocial elements of disability and obstacles to recovery in chronic/long term LBP. Back care education on the other hand has is accepted as an important adjunct to other physiotherapy procedures in the management of low back pain and not necessarily as solely an effective means of managing LBP (Daltroy et al, 1997; Lønn et al, 1999), and evidences supporting back school as sole treatment modality are weak. Endurance exercise however has been reported to be effective in preventing chronic/long-term LBP but has not been investigated in many randomized controlled trials. Optimal functioning of the muscle system is desirable to control and protect the spinal segments following injury. Despite initial resolution of painful symptoms, failure to protect spinal segments could increase the likelihood of a recurrence of symptoms. Specific exercise training targeting the back and abdominal muscles including the multifidus and transversus abdominus muscles have been shown to decrease pain and disability in chronic low back pain patients.

McKenzie's classification is a standardized approach of assessing LBP as it identifies a directional preference for spinal movement which can form basis for classification in treating LBP. When this approach like any other mobilization is used in combination with rehabilitation of the abdominal; and back muscles, much better outcomes may be realized in combating LBP, especially when it is sub-acute, chronic/long-term. Treatment should be individualized, and where group treatment is considered, classification should form the basis of grouping. Group exercise will improve patient interaction and participation which may further ensure better and more specified outcomes and forestall recurrence. Prevention strategies should be introduced early in life, hence more studies to look into low back pain in children and adolescents.

Physical Therapy in the Management of Non-Specific Low Back Pain 241

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*Occupational Medicine: State of the Art Reviews,* 7, 17±31

*Sciences*. 3rd ed. Missouri, Mosby, 449-50, 642-643.

*Management*; 1218, 103-123.

*and Sports Medicine*, 25.

*Back Letter*, 16, 29.

Pain in Primary Care.

20, 192-198.

350.

*Physiotherapy*, 77, 503-508.

therapy. *Physical Therapy*, 72, 885-892.

*Complementary and Alternative Medicine*, 1-6.


Moffroid, M.T. (1997): Endurance Of Trunk Muscles In Persons With Chronic Low Back

Moreau C.E., Green B. N., Johnson C.D.; Moreau S.R. (2001): Isometric back endurance tests:

Mulligan, B.R. (2004): Spinal mobilizations. *Manual Therapy*, 5th ed. New Zealand, APN

Nachemson, A.L. (1990): Exercise; Fitness and Back Pain. In Bouchard R; and Shepherd R.J.

Nelson, B.; O' Reilly, E.; Miller, M.; Hogan J.M.; Wegner, J.; Kelly, C. (1995): The clinical

895 consecutive patients with 1 yr follow-up. *Orthopaedcis*, 18,971-981. Nourbakhsh, M.R.; Arab, A.M. (2002): Relationship between mechanical factors and

Nwuga, V.C.B. (1976): Manipulation of the spine. Baltimore, Williams and Wilkins, 99–105. Nwuga, G.; Nwuga, V. (1985): Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. *Physiotherapy Practice*, 1, 99–105. Nwuga, V.C.B. (2007): A review of history and schools of thought. *Manual Treatment of Back* 

Omokhodion, F.O. (2002): Low back pain in a rural community in South West Nigeria. *West* 

Panjabi, M.M. (1989): Abumi, K.; Duranceau, J.; Oxlandn, T. (1989): Spinal stability and intersegmental muscle forces. A biomechanical model. *Spine*, 14, 194-200. Panjabi, M.M. (1992): The stabilizing system of the spine: Part 1. Function, dysfunction, adaptation, and enhancement. *Journal of Spinal Disorders*, 5, 383–89; discussion, 397 Panjabi, M.M. (1992): The stabilizing system of the spine Part II. Neutral zone and instability

Petersen, T.; Kryger, P.; Ekdahl, C.; Olsen, S.; Jacobsen, J.; (2002): The effects of Mckenzie

Richardson, C.A.; Jull, G. A. (1995): Muscle control–pain control. What exercises would you

Risch, S.V.; Norvell, N.K.; Pollock, L.M. (1993): Lumbar strengthening in chronic low back pain patients: physiologic and psychological benefits. Spine, 18, 232-238. Roach, K. E. Brown, M. D.; Albin, R.D. (1997): The Sensitivity and Specificity of Pain

response to activisty and position in categorizing patients with low back pain.

of patients with sub acute or chronic low back pain. *Spine*, 15, 172-179. Pollock, M.L.; Wilmore, J.H (1990): *Exercise in Health and Disease*. *Evaluation and prescription for Prevention and Rehabilitation*. Philadelphia W.B Saunders, 439-472. Porter R.W. (1993): *The Upright Man*; *Management of Back Pain*.2nd Ed. Longman, Singapore

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**11** 

*Poland* 

**Exercises in Low Back Pain** 

*Department of Clinical Fundamentals of Physiotherapy,* 

*Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University,* 

It is commonly believed that physical exercise plays an important role in the treatment of patients with low back pain (LBP) (Alaranta et al., Bendix et al., 1998; 1994**;** Halldin et al., 2005; Hicks et al., 2005; Hurwitz et al., 2005; Koopman et al., 2004). A serious problem for LBP sufferers is considerable limitation in the range of movement of the trunk and pelvis, often accompanied by shortening of the hamstring tendons and limitation of flexion or extension in the coxofemoral joint. Appropriate dosing of physiological exercise not only improves the condition of soft tissues, but also provides for proper stretching of collagen fibres and enhances the nutrition status of articular cartilage. It is important to prescribe customized programmes of exercises which restore and preserve normal activity of the lumbar spine. An appropriate exercise programme ensures the development of a 'muscle corset' of postural muscles which optimises load on intervertebral discs and passive stabilizers of the spine (ligaments, capsules). Programmes should include stretching as well as endurance- and strength-building exercises. The principle to follow is that movements in joints should be performed within painless limits. Of importance during exercise is appropriate mobility of the lumbar spine–pelvis–lower limb complex. It is often necessary to stretch the hip joint flexors and lumbar extensors as well as to strengthen weak and stretched abdominal and gluteal muscles with the aim of eliminating excessive forward tilt of the pelvis and preventing overload in the lumbar segment as well as ensuring an even

The key to improvement is exercise of spinal muscles to enhance segmental stability, which is compromised by degenerative processes in the disc. Regular physical exercise reduces pain and the accompanying symptoms of depression. Reduction in pain is associated with identifying the most comfortable, 'neutral' position and the ability to assume and maintain

Numerous reports emphasise that abdominal muscles are the key to achieving optimal spinal performance (Alaranta et al., 1994; Axler et al., 1997). An essential activity serving to ensure proper spinal function is controlling the posture and position of the spine during movements so that pain is avoided and the range of movement is as close to normal as possible. The above goals are achieved by ensuring appropriate daily posture, including

**1. Introduction** 

distribution of load.

that position during motor acts.

Krzysztof Radziszewski *Clinic of Rehabilitation,* 

*Military Hospital in Bydgoszcz,* 

Wilmore, Y.H. (1982): *Training for Sport and Activity*. 2nd ed.; Boston Allyn and Bacon inc. 17, 34-69, 116, 236-238.

Zachrisson-Forssell, M. (1980): The Swedish back school. *Physiotherapy*, 66,112-114.

### **Exercises in Low Back Pain**

#### Krzysztof Radziszewski

*Clinic of Rehabilitation, Military Hospital in Bydgoszcz, Department of Clinical Fundamentals of Physiotherapy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Poland* 

#### **1. Introduction**

246 Low Back Pain

Wilmore, Y.H. (1982): *Training for Sport and Activity*. 2nd ed.; Boston Allyn and Bacon inc. 17,

Zachrisson-Forssell, M. (1980): The Swedish back school. *Physiotherapy*, 66,112-114.

34-69, 116, 236-238.

It is commonly believed that physical exercise plays an important role in the treatment of patients with low back pain (LBP) (Alaranta et al., Bendix et al., 1998; 1994**;** Halldin et al., 2005; Hicks et al., 2005; Hurwitz et al., 2005; Koopman et al., 2004). A serious problem for LBP sufferers is considerable limitation in the range of movement of the trunk and pelvis, often accompanied by shortening of the hamstring tendons and limitation of flexion or extension in the coxofemoral joint. Appropriate dosing of physiological exercise not only improves the condition of soft tissues, but also provides for proper stretching of collagen fibres and enhances the nutrition status of articular cartilage. It is important to prescribe customized programmes of exercises which restore and preserve normal activity of the lumbar spine. An appropriate exercise programme ensures the development of a 'muscle corset' of postural muscles which optimises load on intervertebral discs and passive stabilizers of the spine (ligaments, capsules). Programmes should include stretching as well as endurance- and strength-building exercises. The principle to follow is that movements in joints should be performed within painless limits. Of importance during exercise is appropriate mobility of the lumbar spine–pelvis–lower limb complex. It is often necessary to stretch the hip joint flexors and lumbar extensors as well as to strengthen weak and stretched abdominal and gluteal muscles with the aim of eliminating excessive forward tilt of the pelvis and preventing overload in the lumbar segment as well as ensuring an even distribution of load.

The key to improvement is exercise of spinal muscles to enhance segmental stability, which is compromised by degenerative processes in the disc. Regular physical exercise reduces pain and the accompanying symptoms of depression. Reduction in pain is associated with identifying the most comfortable, 'neutral' position and the ability to assume and maintain that position during motor acts.

Numerous reports emphasise that abdominal muscles are the key to achieving optimal spinal performance (Alaranta et al., 1994; Axler et al., 1997). An essential activity serving to ensure proper spinal function is controlling the posture and position of the spine during movements so that pain is avoided and the range of movement is as close to normal as possible. The above goals are achieved by ensuring appropriate daily posture, including

Exercises in Low Back Pain 249

lower and upper limbs in various planes during therapy and, later, during work and everyday activity. The general objectives of such rehabilitation programmes are the alleviation of pain, development of the protective muscular "corset" of the trunk and spine and reduction of the load on intervertebral discs and other elements acting as static stabilisers of the spine (Saal**, (**1990; Tulder et al., 1997). Therapeutic sessions should be carried out in an active manner and repeated only as many times as is necessary for the patient to understand the idea behind the programme and master the exercise technique for later unsupervised practice at home. The programme should also involve instructions for the patient, who should be advised to maintain a neutral spinal position and dynamic muscular "corset" action during all daily activities associated with work and recreation. If no improvement is noted following six therapeutic sessions, the patient should be reevaluated and the rehabilitation specialist consulted. The efficacy of such comprehensive rehabilitation programmes is well-documented and they are widely used in the treatment of

professional athletes (Davies et al., 1979; Delitto et al., 1993; Stankovic et al., 1990).

intervertebral spaces (Beurskens et al., 1997).


supervision or assistance.

health.


Exercises are applied in three basic starting positions:


The choice of a particular starting position is patient-specific.

In acute and subacute low back pain, kinesiotherapy should start with a set of exercises selected individually for the specific patient. Following an evaluation of the patient's exercise capacity, the type of exercises is selected together with starting positions. A comprehensive clinical evaluation serves to identify muscle groups in need of strengthening and those likely to benefit from a relaxing action. Motor re-education of the spine and the musculoligamentous apparatus is necessary. An evaluation of spinal mobility identifies hyper- and hypomobile segments. The therapeutic objective of working with hypermobile segments is to effect their stabilisation, while locked, hypomobile areas must undergo motor mobilisation in order to attain maximum motor harmony. Kinesiotherapy is usually preceded by appropriate physical therapy and followed by relaxation-inducing procedures. The exercise programme emphasises strengthening the abdominal muscles and the quadratus lumborum with simultaneous abolition of the lumbar lordosis. Attention is also given to strengthening the crural muscles, hip extensors and gluteal muscles. The application of traction along the spinal axis may be beneficial. To this end, chair traction can be applied in Perschl position, gravitational traction, or pulsed traction. The duration of a session is from several minutes to half an hour. Traction relaxes back muscles and broadens

Early on, exercises with the patient being hung from pulleys are also possible. When the pain has abated, exercises performed against greater resistance can be introduced, as well as group exercises and further instruction on exercises to be performed by the patient without

The exercises must not produce or intensify pain. Exercises should be selected so that it is possible to mobilise all joint-muscle-ligament systems that influence spinal function and

proper lordotic curvature of the spine. Strong muscles of the abdominal wall are essential as they prevent hyperlordosis and excessive forward tilt of the pelvis. It is necessary to simultaneously stretch the iliopsoas muscles, which are usually contractured from working conditions. At the same time, stretching exercises should be included in the exercise programme to restore the proper position of the spine.

Regular exercise is necessary for surgically managed patients. Early on following intervertebral disc surgery, exercises are mostly concerned with static motor activity and particular attention is paid to pain relief. The exercises aim to improve body posture by strengthening postural muscles, while simultaneously avoiding excessive mobilization of lumbar segments of the spine. In order to reduce pain and structural overload of lumbar segments, water exercises are recommended in small doses. It is believed that, by activating plasminogen, physical exercise may reduce the risk of development of periradicular scars ( Szymanski et al., 1994).

While injury to the intervertebral disc and the resultant low back pain may be due to a variety of causes, the most important of them are believed to include: a stressful lifestyle, incorrect posture, failure to exercise regularly, and physical injury or disease (Biering-Sørensen & Thomsen, 1986). The mechanism of stress-induced BP includes increased tone of the spinal muscles. Good posture depends on adequate flexibility of the hamstring tendons, hip flexors and extensors, and extensor and flexor muscles of the spine, allowing maintenance of proper spinal caurvatures, which is of importance for appropriate loading and function of the spine.

#### **2. Exercises in the acute and subacute phase**

The literature brings conflicting data on the efficacy of exercises to strengthen muscles in the treatment of acute low back pain (Davies et al., 1979; Mitchell & Carmen, 1990; Saal**,** 1990). Some of the inconsistencies stem from methodological shortcomings, randomisation problems or the lack of precise diagnoses in most of these studies (Donchin et al., 1990). In such papers, the advantages of bending exercises in the treatment of various lumbosacral pain syndromes are compared with those of extension exercises. In one study, bending exercises were shown to be useful in patients with pathologies of the posterior segment, such as spondylolysis or spondylolisthesis (Donchin et al., 1990), while other studies demonstrated efficacy of a programme of extension exercises in patients with low back pain of discopathic origin (Delitto et al., 1993; Stankovic & Johnell)**.** The use of unidirectional exercises (only bends or extensions) is principally therapeutic oversimplification, considering the multiplicity of pathophysiological abnormalities found in patients with acute or recurrent low back pain. McKenzie's exercise programme for patients with intervertebral disc pathology concentrates on centralisation of pain rather than on the movements of bending or extending the spine (McKenzie, 1972). However, this programme is introduced only when the positions associated with pain centralisation have been identified **(**Donelson et al., 1990). Therapeutic exercise is incorporated in more complex rehabilitation programmes. Techniques enabling stabilisation of the lumbar spine in motion can be applied simultaneously to ensure dynamic muscle control and protection against biomechanical loads, such as tensing, compression, twisting and shearing action. Spinal stabilisation involves synergistic activation or co-activation of the trunk and spinal muscles in the middle segment of their range of motion. Loads are increased by movements of the

proper lordotic curvature of the spine. Strong muscles of the abdominal wall are essential as they prevent hyperlordosis and excessive forward tilt of the pelvis. It is necessary to simultaneously stretch the iliopsoas muscles, which are usually contractured from working conditions. At the same time, stretching exercises should be included in the exercise

Regular exercise is necessary for surgically managed patients. Early on following intervertebral disc surgery, exercises are mostly concerned with static motor activity and particular attention is paid to pain relief. The exercises aim to improve body posture by strengthening postural muscles, while simultaneously avoiding excessive mobilization of lumbar segments of the spine. In order to reduce pain and structural overload of lumbar segments, water exercises are recommended in small doses. It is believed that, by activating plasminogen, physical exercise may reduce the risk of development of periradicular scars (

While injury to the intervertebral disc and the resultant low back pain may be due to a variety of causes, the most important of them are believed to include: a stressful lifestyle, incorrect posture, failure to exercise regularly, and physical injury or disease (Biering-Sørensen & Thomsen, 1986). The mechanism of stress-induced BP includes increased tone of the spinal muscles. Good posture depends on adequate flexibility of the hamstring tendons, hip flexors and extensors, and extensor and flexor muscles of the spine, allowing maintenance of proper spinal caurvatures, which is of importance for appropriate loading

The literature brings conflicting data on the efficacy of exercises to strengthen muscles in the treatment of acute low back pain (Davies et al., 1979; Mitchell & Carmen, 1990; Saal**,** 1990). Some of the inconsistencies stem from methodological shortcomings, randomisation problems or the lack of precise diagnoses in most of these studies (Donchin et al., 1990). In such papers, the advantages of bending exercises in the treatment of various lumbosacral pain syndromes are compared with those of extension exercises. In one study, bending exercises were shown to be useful in patients with pathologies of the posterior segment, such as spondylolysis or spondylolisthesis (Donchin et al., 1990), while other studies demonstrated efficacy of a programme of extension exercises in patients with low back pain of discopathic origin (Delitto et al., 1993; Stankovic & Johnell)**.** The use of unidirectional exercises (only bends or extensions) is principally therapeutic oversimplification, considering the multiplicity of pathophysiological abnormalities found in patients with acute or recurrent low back pain. McKenzie's exercise programme for patients with intervertebral disc pathology concentrates on centralisation of pain rather than on the movements of bending or extending the spine (McKenzie, 1972). However, this programme is introduced only when the positions associated with pain centralisation have been identified **(**Donelson et al., 1990). Therapeutic exercise is incorporated in more complex rehabilitation programmes. Techniques enabling stabilisation of the lumbar spine in motion can be applied simultaneously to ensure dynamic muscle control and protection against biomechanical loads, such as tensing, compression, twisting and shearing action. Spinal stabilisation involves synergistic activation or co-activation of the trunk and spinal muscles in the middle segment of their range of motion. Loads are increased by movements of the

programme to restore the proper position of the spine.

**2. Exercises in the acute and subacute phase** 

Szymanski et al., 1994).

and function of the spine.

lower and upper limbs in various planes during therapy and, later, during work and everyday activity. The general objectives of such rehabilitation programmes are the alleviation of pain, development of the protective muscular "corset" of the trunk and spine and reduction of the load on intervertebral discs and other elements acting as static stabilisers of the spine (Saal**, (**1990; Tulder et al., 1997). Therapeutic sessions should be carried out in an active manner and repeated only as many times as is necessary for the patient to understand the idea behind the programme and master the exercise technique for later unsupervised practice at home. The programme should also involve instructions for the patient, who should be advised to maintain a neutral spinal position and dynamic muscular "corset" action during all daily activities associated with work and recreation. If no improvement is noted following six therapeutic sessions, the patient should be reevaluated and the rehabilitation specialist consulted. The efficacy of such comprehensive rehabilitation programmes is well-documented and they are widely used in the treatment of professional athletes (Davies et al., 1979; Delitto et al., 1993; Stankovic et al., 1990).

In acute and subacute low back pain, kinesiotherapy should start with a set of exercises selected individually for the specific patient. Following an evaluation of the patient's exercise capacity, the type of exercises is selected together with starting positions. A comprehensive clinical evaluation serves to identify muscle groups in need of strengthening and those likely to benefit from a relaxing action. Motor re-education of the spine and the musculoligamentous apparatus is necessary. An evaluation of spinal mobility identifies hyper- and hypomobile segments. The therapeutic objective of working with hypermobile segments is to effect their stabilisation, while locked, hypomobile areas must undergo motor mobilisation in order to attain maximum motor harmony. Kinesiotherapy is usually preceded by appropriate physical therapy and followed by relaxation-inducing procedures. The exercise programme emphasises strengthening the abdominal muscles and the quadratus lumborum with simultaneous abolition of the lumbar lordosis. Attention is also given to strengthening the crural muscles, hip extensors and gluteal muscles. The application of traction along the spinal axis may be beneficial. To this end, chair traction can be applied in Perschl position, gravitational traction, or pulsed traction. The duration of a session is from several minutes to half an hour. Traction relaxes back muscles and broadens intervertebral spaces (Beurskens et al., 1997).

Exercises are applied in three basic starting positions:


The choice of a particular starting position is patient-specific.

Early on, exercises with the patient being hung from pulleys are also possible. When the pain has abated, exercises performed against greater resistance can be introduced, as well as group exercises and further instruction on exercises to be performed by the patient without supervision or assistance.

The exercises must not produce or intensify pain. Exercises should be selected so that it is possible to mobilise all joint-muscle-ligament systems that influence spinal function and health.

Exercises in Low Back Pain 251

treatment outcomes is compatible with the principles of evidence-based medicine. The method is based on modern technology and therapeutic exercise to produce the best possible functional and analgesic effect. Treatment programmes are individualised. The equipment used in DBC has been designed to enable spinal therapy with repeated dynamic loading. The aim of the programme is to restore segmental spinal motion, improve neuromuscular control of these movements, increase mobility and improve muscle exercise capacity. Free and assisted exercises are applied. The exercise technique contributes to muscular relaxation and relaxes the tensed spinal burso-ligamentous structures. Exercises involve controlled flexion in the sagittal plane, extension, rotation and flexion, and spinal rotation and retraction. Supplementary exercises include general toning and relaxing

Manipulation has been recognised as an effective method in acute low back pain. However, even though some studies have demonstrated the effectiveness of soft tissue manipulation and mobilisation in the treatment of acute low back pain, other studies have not confirmed this effect (Anderson et al., 1972; Koes et al., 1996; Shekelle et al., 1992**;** Tulder **et** al., 1997). Contemporary reports are not reliable due to methodological and procedural shortcomings and the use of poorly measurable parameters for evaluating treatment outcomes. Manipulation should initially be applied once weekly in conjunction with physical exercises. Additionally, supplementary exercises for muscles may be applied two or three times a week. Regular scheduled follow-up visits are necessary to monitor changes in symptoms or signs. The treatment needs to have clear objectives. If there is no improvement after 3-4 sessions, manipulation should be discontinued and the patient re-assessed. Manual techniques should be included in initial treatment of acute low back pain to facilitate physical exercises requiring the patient's active participation. Physicians should be aware of contraindications to manipulation, especially that performed under general anaesthesia, which is associated with considerable risk. While patients undergoing manipulation are very much satisfied with this technique, there is no rationale for performing manipulation

An erect posture is the body's position when standing at ease. Posture changes during life under the influence of the external and internal environment. Serious postural deterioration is usually noted in the fourth decade of life, when the spinal curvatures become more accentuated. This is due to a number of factors: slowly progressive loss of muscle bulk of the abdominal muscles and extensors spinae, gaining weight and degeneration of intervertebral

The lumbar intervertebral discs change with the posture in motion and inactivity. Posture determines the intensity and extent of mechanical tensing of intervertebral discs. Compressive forces acting on the lower lumbar discs decrease nearly to nil in the recumbent position, to increase rapidly in the sitting or standing position. The highest rate of increase in disc compression is associated with physical exertion, especially combined with carrying weights in an inappropriate manner. The intensity of compression depends on the force of gravity and the type and character of the movement being performed. Posture, or the

exercises and exercises to strengthen the muscle groups that

**3.1 Manipulation and mobilisation** 

after acute pain has subsided.

**3.2 Posture** 

discs.

#### **3. Exercises in the chronic phase**

When the symptoms have become chronic, patients practise in small therapeutic groups. Continuous supervision by the physiotherapist is mandatory. An important component of the programme is patient education regarding optimal working conditions during both professional duties and household chores. Lasting good treatment outcomes depend on the patient exercising regularly in the home.

The treatment of back pain is extremely difficult and prolonged. We need to convince the patient that perseverance in systematic kinesiotherapy and maintaining a healthy life style is a must. Low back pain may recur, existing symptoms may exacerbate and new symptoms may develop.

Various criteria are in use for classifying patients as chronic low back pain sufferers. A temporal criterion can be used (symptoms have been present for more than 6 months) or a symptom-based one (despite back pain, the patient is able to carry on daily activity, including professional duties, be it with some limitations from time to time). Rehabilitation programmes for chronic back pain sufferers are also administered to patients after spinal surgery. Chronic low back pain is characterized by lower pain intensity, a constant level of spinal dysfunction and the presence of permanent neurological deficits. In the chronic low back pain phase, patients often appear depressed and anxious. These are important factors affecting patient motivation to carry out therapeutic exercises. Kinesiotherapy in the chronic phase is based on similar principles as treatment in the acute phase. Differences concern the pace of exercises, loads and exercise types. After exercising individually, the patients can soon join a therapeutic group performing group exercises. Individual exercises should be available to patients following spinal surgery or early on during a symptomatic exacerbation. In patients after spinal surgery, the decision to commence kinesiotherapy must be preceded by collecting detailed information about the operative procedure and the presence of any contraindications to rehabilitation.

Exercises to strengthen weakened phasic muscles are introduced when contractured muscles have been relaxed. An effective way to relax contractured postural muscles is to apply post-isometric muscle relaxation. This technique demands co-operation of the therapist and patient, who contributes to the technique of relaxation. The therapist achieves mild extension of the contractured muscle. The patient uses a minimum force to tense the muscle against the resistance afforded by the therapist's hand for approximately 10 seconds. This is followed by a muscle relaxation phase, lasting 2-3 seconds. As resistance subsides, the therapist gently extends the contractured muscle over several seconds. This cycle should be repeated a few times for each contractured muscle. Exercises associated with uncontrolled extension of passive vertebral stabilisers (ligaments, joint capsules) should be avoided as this may impair spinal stability.

Abdominal muscles are to be strengthened mainly via isometric contractions. Isotonic exercises should only be performed in the supine position. Exercises should be simple and easy to learn and carry out. Exercise intensity should match the patient's capabilities at a given time. The move from less demanding to more strenuous exercises should be gradual.

The DBC method (Documentation Based Care) is a form of kinesiotherapy based on mechanotherapy. It is an active therapy for subacute and chronic spinal ailments. The name emphasizes its documentation-based rationale. The approach to evaluating and analysing

When the symptoms have become chronic, patients practise in small therapeutic groups. Continuous supervision by the physiotherapist is mandatory. An important component of the programme is patient education regarding optimal working conditions during both professional duties and household chores. Lasting good treatment outcomes depend on the

The treatment of back pain is extremely difficult and prolonged. We need to convince the patient that perseverance in systematic kinesiotherapy and maintaining a healthy life style is a must. Low back pain may recur, existing symptoms may exacerbate and new symptoms

Various criteria are in use for classifying patients as chronic low back pain sufferers. A temporal criterion can be used (symptoms have been present for more than 6 months) or a symptom-based one (despite back pain, the patient is able to carry on daily activity, including professional duties, be it with some limitations from time to time). Rehabilitation programmes for chronic back pain sufferers are also administered to patients after spinal surgery. Chronic low back pain is characterized by lower pain intensity, a constant level of spinal dysfunction and the presence of permanent neurological deficits. In the chronic low back pain phase, patients often appear depressed and anxious. These are important factors affecting patient motivation to carry out therapeutic exercises. Kinesiotherapy in the chronic phase is based on similar principles as treatment in the acute phase. Differences concern the pace of exercises, loads and exercise types. After exercising individually, the patients can soon join a therapeutic group performing group exercises. Individual exercises should be available to patients following spinal surgery or early on during a symptomatic exacerbation. In patients after spinal surgery, the decision to commence kinesiotherapy must be preceded by collecting detailed information about the operative procedure and the

Exercises to strengthen weakened phasic muscles are introduced when contractured muscles have been relaxed. An effective way to relax contractured postural muscles is to apply post-isometric muscle relaxation. This technique demands co-operation of the therapist and patient, who contributes to the technique of relaxation. The therapist achieves mild extension of the contractured muscle. The patient uses a minimum force to tense the muscle against the resistance afforded by the therapist's hand for approximately 10 seconds. This is followed by a muscle relaxation phase, lasting 2-3 seconds. As resistance subsides, the therapist gently extends the contractured muscle over several seconds. This cycle should be repeated a few times for each contractured muscle. Exercises associated with uncontrolled extension of passive vertebral stabilisers (ligaments, joint capsules) should be

Abdominal muscles are to be strengthened mainly via isometric contractions. Isotonic exercises should only be performed in the supine position. Exercises should be simple and easy to learn and carry out. Exercise intensity should match the patient's capabilities at a given time. The move from less demanding to more strenuous exercises should be gradual. The DBC method (Documentation Based Care) is a form of kinesiotherapy based on mechanotherapy. It is an active therapy for subacute and chronic spinal ailments. The name emphasizes its documentation-based rationale. The approach to evaluating and analysing

**3. Exercises in the chronic phase** 

patient exercising regularly in the home.

presence of any contraindications to rehabilitation.

avoided as this may impair spinal stability.

may develop.

treatment outcomes is compatible with the principles of evidence-based medicine. The method is based on modern technology and therapeutic exercise to produce the best possible functional and analgesic effect. Treatment programmes are individualised. The equipment used in DBC has been designed to enable spinal therapy with repeated dynamic loading. The aim of the programme is to restore segmental spinal motion, improve neuromuscular control of these movements, increase mobility and improve muscle exercise capacity. Free and assisted exercises are applied. The exercise technique contributes to muscular relaxation and relaxes the tensed spinal burso-ligamentous structures. Exercises involve controlled flexion in the sagittal plane, extension, rotation and flexion, and spinal rotation and retraction. Supplementary exercises include general toning and relaxing exercises and exercises to strengthen the muscle groups that

#### **3.1 Manipulation and mobilisation**

Manipulation has been recognised as an effective method in acute low back pain. However, even though some studies have demonstrated the effectiveness of soft tissue manipulation and mobilisation in the treatment of acute low back pain, other studies have not confirmed this effect (Anderson et al., 1972; Koes et al., 1996; Shekelle et al., 1992**;** Tulder **et** al., 1997). Contemporary reports are not reliable due to methodological and procedural shortcomings and the use of poorly measurable parameters for evaluating treatment outcomes. Manipulation should initially be applied once weekly in conjunction with physical exercises. Additionally, supplementary exercises for muscles may be applied two or three times a week. Regular scheduled follow-up visits are necessary to monitor changes in symptoms or signs. The treatment needs to have clear objectives. If there is no improvement after 3-4 sessions, manipulation should be discontinued and the patient re-assessed. Manual techniques should be included in initial treatment of acute low back pain to facilitate physical exercises requiring the patient's active participation. Physicians should be aware of contraindications to manipulation, especially that performed under general anaesthesia, which is associated with considerable risk. While patients undergoing manipulation are very much satisfied with this technique, there is no rationale for performing manipulation after acute pain has subsided.

#### **3.2 Posture**

An erect posture is the body's position when standing at ease. Posture changes during life under the influence of the external and internal environment. Serious postural deterioration is usually noted in the fourth decade of life, when the spinal curvatures become more accentuated. This is due to a number of factors: slowly progressive loss of muscle bulk of the abdominal muscles and extensors spinae, gaining weight and degeneration of intervertebral discs.

The lumbar intervertebral discs change with the posture in motion and inactivity. Posture determines the intensity and extent of mechanical tensing of intervertebral discs. Compressive forces acting on the lower lumbar discs decrease nearly to nil in the recumbent position, to increase rapidly in the sitting or standing position. The highest rate of increase in disc compression is associated with physical exertion, especially combined with carrying weights in an inappropriate manner. The intensity of compression depends on the force of gravity and the type and character of the movement being performed. Posture, or the

Exercises in Low Back Pain 253


Posterior inclination of the pelvis when carrying weights and performing exercises is recommended by many textbooks. This habit leads to spinal flexion and, from the very outset, puts a strain on the annulus fibrosus and posterior spinal ligaments, potentially increasing the risk of damage to the intervertebral disc. A neutrally aligned spinal column (i.e. one that is neither in hyper- or hypolordosis) provides for elastic balance and minimises the risk of damage during increased strain on the spine as a result of muscular contractions. A general practical rule to follow is that the normal lumbo-sacral spinal curvatures should

Exercises to enhance trunk flexibility should be limited to the movements of flexion and extension without loading. It is not advisable to attempt to attain the extremes of spinal mobility in particular types of damage (Battié et al., 1990; McGill,1998). The outcomes of numerous rehabilitation programmes confirm the importance of achieving trunk stability through exercises with the spine in a neutral position. It is emphasized that ensuring normal

Appropriate mobility in the hip and knee joints is required for the maintenance of spinesparing postures. Normal mobility in the hip and knee joints is necessary to protect the

The effectiveness of muscle action is determined by "strength" and "endurance", which should be treated as two different components, especially with regard to planning specific exercise programmes. "Strength" refers to the maximum force that a muscle can produce during a single effort to produce torque in a joint. "Endurance" denotes the ability to exert a sustained force over some time. Decreased muscle strength in patients with spinal pathology is a proven fact (McNeill et al., 1980). Several works have suggested that endurance is more important than strength in prevention (McGill, 1998); McNeill et al., 1980). Many injuries occurring during submaximum efforts are associated with decreased endurance of spinal muscles. Patients with spinal pathology need to ensure necessary stabilisation by tensing their abdominal muscles in the erect position, and especially during flexion. While planning exercises, emphasis should be placed on improving endurance by the application of exercises that take longer to complete but generate less loading **(**Cady et al., 1979; McNeill et al., 1980). An important aspect of the methodology of endurancebuilding exercises is that such exercises do not involve joint movements, which facilitates

Increased intraabdominal pressures are used to stabilise and protect the lumbar spine during movements and carrying weights. Intraabdominal pressure can be increased by appropriate

stability and a safe amplitude of movement.

mobility in the hip and knee joints is essential.

**3.5 Strength and endurance** 

activation of the abdominal muscles.

**3.6 Abdominal muscles** 

spine from excessive movements during daily activity.

be maintained as they shape out in an erect position **(**McGill,1998).

**3.3 Pelvic tilt** 

**3.4 The flexibility** 

alignment of vertebral bodies against each other and the alignment of the spine along the vertical axis, is of considerable importance for the prevention of back pain.

In the standing position, body mass is distributed equally between vertebral bodies and intervertebral discs. If the spine deviates from the vertical plane, a system of levers begins to operate which increases the pressure acting on intervertebral discs several times. The increase in intervertebral disc compression is the result of the lever action and changes in the plane of action of the levers. The compressive forces do not act on the discs and vertebral bodies at a right angle, but at an acute angle. Shearing forces arise and attempt to dislocate the vertebrae. These shearing forces are counteracted by the intervertebral discs, ligaments, articular processes, and muscles that stabilize the spine.

Changes in vertebral alignment during movement of the spine predominantly affect the annulus fibrosus of the intervertebral disc. Forward and lateral bends, straightening, rotations, or any combinations of these movements, stretch and tense annulus fibrosus fibres. The degree of tensing depends on the amplitude of the movement being performed. The nucleus pulposus takes part in all movements. The gel of the nucleus pulposus is intertwined with the fibrous tissue network growing into the annulus fibrosus. Movements of the spine lead to various degrees of tensing of this fibrous network and the annulus fibrosus. Similarly, forces attempting to dislocate vertebrae are transferred onto the fibrous network and the annulus. These forces, whose intensity depends partially on spinal mobility and partially on posture, have a major influence on degenerative processes within the intervertebral disc. Control of these forces is of basic importance for prevention and the treatment of patients with intervertebral disc damage. Protecting the ailing disc from harmful tensing and loading is a preprequisite for the process of fibrous ankylosis of the affected spinal segment that often produces abolition of symptoms. It is not possible to "switch off" all forces and tensions acting on the lumbar spine. These forces can be reduced and so can their harmful effects. An important role in this regard is played by the maintenance of an appropriate posture both at work and at rest. This must be paralleled by strengthening the muscles that stabilize the lumbar spine.

Good posture plays a major role in protecting the lumbar intervertebral discs from mechanical overload. When the lumbar spine is properly stabilized, a strong extensor spinae and abdominal muscles bear the brunt of many forces that would otherwise be acting directly on the spinal ligaments and joints and intervertebral discs. When an intervertebral disc is damaged, the role of good posture is to ensure maximum spinal performance while simultaneously reducing pressures acting on the spine. Controlling spinal movements prevents repetitive overload of the strands of elastic fibres of the annulus fibrosus and the nucleus pulposus.

Any prevention programme for low back pain should be based on several principles:



#### **3.3 Pelvic tilt**

252 Low Back Pain

alignment of vertebral bodies against each other and the alignment of the spine along the

In the standing position, body mass is distributed equally between vertebral bodies and intervertebral discs. If the spine deviates from the vertical plane, a system of levers begins to operate which increases the pressure acting on intervertebral discs several times. The increase in intervertebral disc compression is the result of the lever action and changes in the plane of action of the levers. The compressive forces do not act on the discs and vertebral bodies at a right angle, but at an acute angle. Shearing forces arise and attempt to dislocate the vertebrae. These shearing forces are counteracted by the intervertebral discs, ligaments,

Changes in vertebral alignment during movement of the spine predominantly affect the annulus fibrosus of the intervertebral disc. Forward and lateral bends, straightening, rotations, or any combinations of these movements, stretch and tense annulus fibrosus fibres. The degree of tensing depends on the amplitude of the movement being performed. The nucleus pulposus takes part in all movements. The gel of the nucleus pulposus is intertwined with the fibrous tissue network growing into the annulus fibrosus. Movements of the spine lead to various degrees of tensing of this fibrous network and the annulus fibrosus. Similarly, forces attempting to dislocate vertebrae are transferred onto the fibrous network and the annulus. These forces, whose intensity depends partially on spinal mobility and partially on posture, have a major influence on degenerative processes within the intervertebral disc. Control of these forces is of basic importance for prevention and the treatment of patients with intervertebral disc damage. Protecting the ailing disc from harmful tensing and loading is a preprequisite for the process of fibrous ankylosis of the affected spinal segment that often produces abolition of symptoms. It is not possible to "switch off" all forces and tensions acting on the lumbar spine. These forces can be reduced and so can their harmful effects. An important role in this regard is played by the maintenance of an appropriate posture both at work and at rest. This must be paralleled by

Good posture plays a major role in protecting the lumbar intervertebral discs from mechanical overload. When the lumbar spine is properly stabilized, a strong extensor spinae and abdominal muscles bear the brunt of many forces that would otherwise be acting directly on the spinal ligaments and joints and intervertebral discs. When an intervertebral disc is damaged, the role of good posture is to ensure maximum spinal performance while simultaneously reducing pressures acting on the spine. Controlling spinal movements prevents repetitive overload of the strands of elastic fibres of the annulus fibrosus and the

Any prevention programme for low back pain should be based on several principles:




vertical axis, is of considerable importance for the prevention of back pain.

articular processes, and muscles that stabilize the spine.

strengthening the muscles that stabilize the lumbar spine.

straightening or rotation are to be avoided,

likelihood of the development of shearing forces,

nucleus pulposus.

appropriate tone,

Posterior inclination of the pelvis when carrying weights and performing exercises is recommended by many textbooks. This habit leads to spinal flexion and, from the very outset, puts a strain on the annulus fibrosus and posterior spinal ligaments, potentially increasing the risk of damage to the intervertebral disc. A neutrally aligned spinal column (i.e. one that is neither in hyper- or hypolordosis) provides for elastic balance and minimises the risk of damage during increased strain on the spine as a result of muscular contractions. A general practical rule to follow is that the normal lumbo-sacral spinal curvatures should be maintained as they shape out in an erect position **(**McGill,1998).

#### **3.4 The flexibility**

Exercises to enhance trunk flexibility should be limited to the movements of flexion and extension without loading. It is not advisable to attempt to attain the extremes of spinal mobility in particular types of damage (Battié et al., 1990; McGill,1998). The outcomes of numerous rehabilitation programmes confirm the importance of achieving trunk stability through exercises with the spine in a neutral position. It is emphasized that ensuring normal mobility in the hip and knee joints is essential.

Appropriate mobility in the hip and knee joints is required for the maintenance of spinesparing postures. Normal mobility in the hip and knee joints is necessary to protect the spine from excessive movements during daily activity.

#### **3.5 Strength and endurance**

The effectiveness of muscle action is determined by "strength" and "endurance", which should be treated as two different components, especially with regard to planning specific exercise programmes. "Strength" refers to the maximum force that a muscle can produce during a single effort to produce torque in a joint. "Endurance" denotes the ability to exert a sustained force over some time. Decreased muscle strength in patients with spinal pathology is a proven fact (McNeill et al., 1980). Several works have suggested that endurance is more important than strength in prevention (McGill, 1998); McNeill et al., 1980). Many injuries occurring during submaximum efforts are associated with decreased endurance of spinal muscles. Patients with spinal pathology need to ensure necessary stabilisation by tensing their abdominal muscles in the erect position, and especially during flexion. While planning exercises, emphasis should be placed on improving endurance by the application of exercises that take longer to complete but generate less loading **(**Cady et al., 1979; McNeill et al., 1980). An important aspect of the methodology of endurancebuilding exercises is that such exercises do not involve joint movements, which facilitates activation of the abdominal muscles.

#### **3.6 Abdominal muscles**

Increased intraabdominal pressures are used to stabilise and protect the lumbar spine during movements and carrying weights. Intraabdominal pressure can be increased by appropriate

Exercises in Low Back Pain 255

lower spine (Cady et al., 1979) and in the treatment of patients with low back pain is well

Some studies raise the causality question as low back pain often affects professional athletes, who have excellent aerobic capacity. Casazza et al. reviewed the available literature on the role of aerobic training and improving cardiovascular performance. They found that it is not clear whether it is low back pain that leads to decreased exercise capacity or whether reduced exercise capacity contributes to the development of low back pain. The authors noted that low back pain has lower intensity in patients with normal exercise capacity and they are convinced that there is a rationale for including aerobic exercise in the rehabilitation programme (Casazza et al, 1998). Videman et al. revealed the presence of more advanced degenerative changes and disc protrusion in weight-lifters and footballers compared to

Improved aerobic capacity may increase perfusion and oxygen supply to all tissues, including muscles, vertebrae and spinal ligaments. Aerobic exercise may reduce the influence of mental factors on low back pain by improving mood, diminishing depression and increasing pain tolerance **(**Anshel **&** Russell, 1994). It is theoretically possible that such exercises increase the body's ability to lyse scar tissue via the action of tissue plasminogen activator (Szymanski & Pate, 1994). Improvement of aerobic capacity should be combined with a rehabilitation programme aiming to restore normal mobility of the lumbosacral spine, strengthen trunk muscles and restore normal body mechanics. Limiting rehabilitation to aerobic exercise would not be sufficient. It is important to avoid situations that reduce exercise capacity. This principle can be implemented at the very start of treatment by reducing the length of the period of bed rest and immobilisation. Patients with decreased overall exercise capacity should be instructed about the basics of aerobic exercise and evaluation of target exercise intensity by measuring

Particular importance is ascribed to exercising regularly (Ben Salah Frih et al., 2009). Temporary, emergency rehabilitation of patients with disc herniation at L4-L5 does not prevent disease progression. Failure to exercise regularly affects patients' physical performance and results in inability to work and perform self-care in more than 22% of patients within 2 years (Friedrich, 2005). The results of Laursen's observations confirm that regular rehabilitation is indispensable in conservative therapy (Laursen & Fugl**,** 1995). Observations show that exercise intensity does not have a significant effect on long-term outcomes of rehabilitation of patients with LBP (Mellin et al, 1993). During the immediate post-operative period, programmes of intensive exercises produce better outcomes.

It is also often emphasised that regular physical exercise has a favourable effect on surgical outcomes in intervertebral disc herniation. The discopathic patient should not wait for a miracle cure to relieve the dysfunction and suffering completely and permanently but should start to participate actively in the treatment process. Intensive exercise from the 4th – 6th week after surgery onwards significantly improves the functional status of patients and reduces the time needed to return to work. A programme of motor rehabilitation introduced at a later stage does not produce such favourable therapeutic effects (Ostelo et al.**,** 2003).

documented (Nutter, 1988).

runners (Videman, 1976).

the heart rate or assessing subjective fatigue.

(Friedrich et al., 2005; Ostelo et al.**,** 2003).

**3.10 Regular physical exercise** 

exercises for the rectus abdominis and oblique abdominis muscles. Improvement in abdominal muscle strength and tonus enhances the efficacy of the mechanism for transferring loads and mechanical strain from the skeleton to the muscular system by increasing intraabdominal pressure. As a result, some of the forces representing a load on the lower intervertebral discs are transferred to the pelvic floor and the diaphragm. Moreover, improved abdominal muscle strength helps stabilize the spine better. In the lumbar region, the spine is supported posteriorly by the extensor spinae, anterolaterally by the psoas, and anteriorly by intraabdominal pressure, which depends on abdominal muscle tone.

No single exercise will help develop all abdominal muscles. If the goal is to improve muscle strength and endurance, exercises should be prescribed in increased quantities. Trunk curlups mainly strengthen the rectus abdominis with little activity from the psoas muscles and the muscles of the abdominal wall (internal and external oblique and transverse abdominal muscle). Raising an erect trunk (sit-ups), with the lower limbs extended or flexed at the knee, increases psoas activity and increases pressure on the lower spine. Leg raising considerably increases muscle activity and pressure on the spine.

Exercises in the lateral recumbent position are a useful type of exercise for low back pain sufferers as they involve the lateral oblique muscles without generating much load on the lumbar region. These exercises also trigger considerable activity of the quadratus lumborum, which is the most important spinal stabiliser. At the beginning of rehabilitation, exercises for abdominal muscles should involve elevating a curled-up trunk and isometric exercises in the lateral recumbent position with support at the knee and the flexed elbow (Axler & McGill, 1997; Hurwitz et al., 2005).

#### **3.7 Quadratus lumborum muscle**

It has been questioned whether the psoas muscle is indeed an important stabiliser of the spine. The activity of the psoas muscles is mostly seen during hip flexion. During flexion and axial loading of the lumbar spine, it is the quadratus lumborum that exhibits greater activity. This suggests an important role for the quadratus lumborum in stabilising the lumbar spine. Strengthening the quadratus lumborum muscle and increasing spinal stability can be achieved with exercises in horizontal lateral support (McGill et al., 1996).

#### **3.8 Extensor spinae**

Most exercises for the extensor spinae muscles are associated with considerable load on the spine produced by externally generated pressure and shearing forces.

Exercises involving keeping one leg extended with the body being supported on the hands and the other knee produce little external loading of the spine but simultaneously generate an extension torque, resulting in increased activity of the extensor spinae muscles. Unilateral extensor spinae activity is sufficient. Since the activity of the contralateral extensor spina eis low, the total load on the spine is decreased. Alternate extension of the lower limbs produces alternate engagement of the extensors spinae (Hurwitz et al., 2005).

#### **3.9 Aerobic exercises**

Numerous studies have revealed that low back pain sufferers demonstrate reduced aerobic capacity. The importance of aerobic exercise in reducing the incidence of pathology of the

exercises for the rectus abdominis and oblique abdominis muscles. Improvement in abdominal muscle strength and tonus enhances the efficacy of the mechanism for transferring loads and mechanical strain from the skeleton to the muscular system by increasing intraabdominal pressure. As a result, some of the forces representing a load on the lower intervertebral discs are transferred to the pelvic floor and the diaphragm. Moreover, improved abdominal muscle strength helps stabilize the spine better. In the lumbar region, the spine is supported posteriorly by the extensor spinae, anterolaterally by the psoas, and anteriorly by

No single exercise will help develop all abdominal muscles. If the goal is to improve muscle strength and endurance, exercises should be prescribed in increased quantities. Trunk curlups mainly strengthen the rectus abdominis with little activity from the psoas muscles and the muscles of the abdominal wall (internal and external oblique and transverse abdominal muscle). Raising an erect trunk (sit-ups), with the lower limbs extended or flexed at the knee, increases psoas activity and increases pressure on the lower spine. Leg raising

Exercises in the lateral recumbent position are a useful type of exercise for low back pain sufferers as they involve the lateral oblique muscles without generating much load on the lumbar region. These exercises also trigger considerable activity of the quadratus lumborum, which is the most important spinal stabiliser. At the beginning of rehabilitation, exercises for abdominal muscles should involve elevating a curled-up trunk and isometric exercises in the lateral recumbent position with support at the knee and the flexed elbow

It has been questioned whether the psoas muscle is indeed an important stabiliser of the spine. The activity of the psoas muscles is mostly seen during hip flexion. During flexion and axial loading of the lumbar spine, it is the quadratus lumborum that exhibits greater activity. This suggests an important role for the quadratus lumborum in stabilising the lumbar spine. Strengthening the quadratus lumborum muscle and increasing spinal stability

Most exercises for the extensor spinae muscles are associated with considerable load on the

Exercises involving keeping one leg extended with the body being supported on the hands and the other knee produce little external loading of the spine but simultaneously generate an extension torque, resulting in increased activity of the extensor spinae muscles. Unilateral extensor spinae activity is sufficient. Since the activity of the contralateral extensor spina eis low, the total load on the spine is decreased. Alternate extension of the lower limbs

Numerous studies have revealed that low back pain sufferers demonstrate reduced aerobic capacity. The importance of aerobic exercise in reducing the incidence of pathology of the

can be achieved with exercises in horizontal lateral support (McGill et al., 1996).

spine produced by externally generated pressure and shearing forces.

produces alternate engagement of the extensors spinae (Hurwitz et al., 2005).

intraabdominal pressure, which depends on abdominal muscle tone.

considerably increases muscle activity and pressure on the spine.

(Axler & McGill, 1997; Hurwitz et al., 2005).

**3.7 Quadratus lumborum muscle** 

**3.8 Extensor spinae** 

**3.9 Aerobic exercises** 

lower spine (Cady et al., 1979) and in the treatment of patients with low back pain is well documented (Nutter, 1988).

Some studies raise the causality question as low back pain often affects professional athletes, who have excellent aerobic capacity. Casazza et al. reviewed the available literature on the role of aerobic training and improving cardiovascular performance. They found that it is not clear whether it is low back pain that leads to decreased exercise capacity or whether reduced exercise capacity contributes to the development of low back pain. The authors noted that low back pain has lower intensity in patients with normal exercise capacity and they are convinced that there is a rationale for including aerobic exercise in the rehabilitation programme (Casazza et al, 1998). Videman et al. revealed the presence of more advanced degenerative changes and disc protrusion in weight-lifters and footballers compared to runners (Videman, 1976).

Improved aerobic capacity may increase perfusion and oxygen supply to all tissues, including muscles, vertebrae and spinal ligaments. Aerobic exercise may reduce the influence of mental factors on low back pain by improving mood, diminishing depression and increasing pain tolerance **(**Anshel **&** Russell, 1994). It is theoretically possible that such exercises increase the body's ability to lyse scar tissue via the action of tissue plasminogen activator (Szymanski & Pate, 1994). Improvement of aerobic capacity should be combined with a rehabilitation programme aiming to restore normal mobility of the lumbosacral spine, strengthen trunk muscles and restore normal body mechanics. Limiting rehabilitation to aerobic exercise would not be sufficient. It is important to avoid situations that reduce exercise capacity. This principle can be implemented at the very start of treatment by reducing the length of the period of bed rest and immobilisation. Patients with decreased overall exercise capacity should be instructed about the basics of aerobic exercise and evaluation of target exercise intensity by measuring the heart rate or assessing subjective fatigue.

#### **3.10 Regular physical exercise**

Particular importance is ascribed to exercising regularly (Ben Salah Frih et al., 2009). Temporary, emergency rehabilitation of patients with disc herniation at L4-L5 does not prevent disease progression. Failure to exercise regularly affects patients' physical performance and results in inability to work and perform self-care in more than 22% of patients within 2 years (Friedrich, 2005). The results of Laursen's observations confirm that regular rehabilitation is indispensable in conservative therapy (Laursen & Fugl**,** 1995). Observations show that exercise intensity does not have a significant effect on long-term outcomes of rehabilitation of patients with LBP (Mellin et al, 1993). During the immediate post-operative period, programmes of intensive exercises produce better outcomes. (Friedrich et al., 2005; Ostelo et al.**,** 2003).

It is also often emphasised that regular physical exercise has a favourable effect on surgical outcomes in intervertebral disc herniation. The discopathic patient should not wait for a miracle cure to relieve the dysfunction and suffering completely and permanently but should start to participate actively in the treatment process. Intensive exercise from the 4th – 6th week after surgery onwards significantly improves the functional status of patients and reduces the time needed to return to work. A programme of motor rehabilitation introduced at a later stage does not produce such favourable therapeutic effects (Ostelo et al.**,** 2003).

Exercises in Low Back Pain 257

stabilization of the motor segments of the spine, improved posture and increased overall physical capacity of the body. The precise mechanism by which exercise alleviates pain has not been fully elucidated, although it may be associated with enhancing the nutrition status of the disc. Physical exercise, by stimulating changes in pressure within the intervertebral

The methodology of exercise attributes a significant role to strength- and endurancebuilding exercises. Muscle strength is of key importance for trunk stability. Augmentation of the spinal curvatures may be due to weakening of the paraspinal muscles. Epidemiologic studies have shown that patients with strong muscles less frequently complain of back pain. In healthy people, the extensor muscles of the trunk are stronger by 30% than the flexor muscles. However, it is believed that decreased strength is less important in back pain syndromes than decreased endurance capacity of dorsal and abdominal muscles (Davies et

Exercise accelerates repair and substitution processes in the musculoskeletal system and internal organs, and prevents the development of detrimental substitute motor patterns. It also prevents the development of secondary changes in bones, joints, muscles and ligaments and cardiorespiratory complications. The body's overall physical capacity is also improved. The main aim of exercises involving movement is to break the vicious circle of pain by reducing reflex increase in paraspinal muscle tension. Exercise also serves to improve stability of the lumbar spine by increasing intraabdominal pressure and restoring muscle balance, which prevents the recurrence of symptoms. Kinesiotherapy in low back pain should be well chosen and appropriately dosed. The notion of choice applies to exercise duration, the number of repetitions of an exercise and the duration of a series of exercises.

An exercise programme should begin with cycles of flexion and extension exercises serving to decrease stiffness and relax elastic structures. This will result in decreased load on the spinal joints during further exercises. The next batch of exercises should serve to improve mobility in the hip and knee joints and should be followed by exercises for the main spinal stabilisers, starting from abdominal muscles, with the spine in a neutral position throughout this stage. These, in turn, are followed by an ordered sequence of exercises in lateral support to strengthen the quadratus lumborum and oblique abdominis muscles, and exercises for the extensors spinae. The programme should be individualized with regard to the number of repetitions and duration of individual exercise items. The goals need to be clearly specified. Importantly, exercises should be performed in the pain-free range as much as possible. General fitness exercises should not be omitted from a programme for rehabilitation of low back pain sufferers (Nutter, 1988). A basic objective of the exercise set recommended by us is to restore normal static and dynamic balance and motor patterns. Improvement in motor function and alleviation of pain can often be observed following several months of exercises (Donchin et al., 1990 ; McGill**,** 1998). Of significance for LBP prevention is compliance with the principles of ergonomics during daily activities.(Zauner-

The most important types of exercise for preventing low back pain are exercises for abdominal muscles, dorsal muscles, gluteal muscles and quadratus lumborum muscle. The

disc, may improve the mechanisms of osmosis that underlie disc nutrition.

The technique of therapeutic exercises is also important.

al., 1979; McGill**,** 1998).

Dungl et al., 2004))

**5. Conclusion** 

Kjellby argues that repeat surgery is less common in patients engaged in rehabilitation programmes (Kjellby**-**Wendt et al., 2002).

Patients with acute and subacute low back pain perform exercises most regularly. A study by the present author found that the proportion of those patients exercising and the amount of time devoted to exercise weekly increased with the duration of the disease. Within 6 months following the onset of back pain, 51.4% of patients performed spinal exercises regularly, of whom only 15.4% exercised for 2 hours a week. In long-term follow-up (5 years after onset), 53.6% of respondents reported exercising regularly, 17.9% of whom exercised for more than 2 hours a week.


Table 1. Treatment outcomes according to the time alloted to exercise per week

Surgically managed patients appreciated the importance of regular exercise the most during immediate and short-term follow-up. In this period, about 60% of patients reported performing therapeutic exercises, with most, however, exercising for one hour per week. At four years post-surgery, the total number of exercising patients had decreased by approximately 4%, while the number of patients exercising for more than 2-3 hours a week had risen by approximately 4%. Physical exercise was performed by 58.8% of men and 50.4% of women. A beneficial effect of exercise on the functional status, pain intensity and mental state was recorded only in the group exercising for more than two hours a week. The study indicated that the use of physical exercise by patients with low back pain is insufficient, with only approximately 20% of patients exercising long enough. Patients definitely prefer passive treatments to alleviate pain (massage, physiotherapy). Exercises of the backbone are performed for a short period, irregularly and usually only when the pain is more intense. Therefore, the exercises cannot wholly fulfil the important preventive and therapeutic role they are attributed (Radziszewski, 2007).

#### **4. Summary**

Numerous authors emphasise that a programme of regular motor rehabilitation is the most efficient modality of conservative therapy (Alaranta et al., 1994; Caby et al., 2010; Kjellby**-**Wendt et al., 2002; Koopman et al., 2004; Sherman et al., 2010). Regular physical exercise is a way to achieve many beneficial effects, such as reduction of pain, strengthening of the spinal muscles, optimisation of the distribution of load on the spinal structures, enhanced

Kjellby argues that repeat surgery is less common in patients engaged in rehabilitation

Patients with acute and subacute low back pain perform exercises most regularly. A study by the present author found that the proportion of those patients exercising and the amount of time devoted to exercise weekly increased with the duration of the disease. Within 6 months following the onset of back pain, 51.4% of patients performed spinal exercises regularly, of whom only 15.4% exercised for 2 hours a week. In long-term follow-up (5 years after onset), 53.6% of respondents reported exercising regularly, 17.9% of whom exercised

LESS THAN

V-A scale (1-10) 4,511,72 4,121,26 3,352,31

(% of normal) 50,811,3 52,89,6 59,98,4

Table 1. Treatment outcomes according to the time alloted to exercise per week

therapeutic role they are attributed (Radziszewski, 2007).

Surgically managed patients appreciated the importance of regular exercise the most during immediate and short-term follow-up. In this period, about 60% of patients reported performing therapeutic exercises, with most, however, exercising for one hour per week. At four years post-surgery, the total number of exercising patients had decreased by approximately 4%, while the number of patients exercising for more than 2-3 hours a week had risen by approximately 4%. Physical exercise was performed by 58.8% of men and 50.4% of women. A beneficial effect of exercise on the functional status, pain intensity and mental state was recorded only in the group exercising for more than two hours a week. The study indicated that the use of physical exercise by patients with low back pain is insufficient, with only approximately 20% of patients exercising long enough. Patients definitely prefer passive treatments to alleviate pain (massage, physiotherapy). Exercises of the backbone are performed for a short period, irregularly and usually only when the pain is more intense. Therefore, the exercises cannot wholly fulfil the important preventive and

Numerous authors emphasise that a programme of regular motor rehabilitation is the most efficient modality of conservative therapy (Alaranta et al., 1994; Caby et al., 2010; Kjellby**-**Wendt et al., 2002; Koopman et al., 2004; Sherman et al., 2010). Regular physical exercise is a way to achieve many beneficial effects, such as reduction of pain, strengthening of the spinal muscles, optimisation of the distribution of load on the spinal structures, enhanced

TIME PER WEEK

2 HOURS

1 HUOR 1-2 HOURS MORE THAN

63,121,0 57,711,1 59,821.3

0,610,12 0,560,10 0,480,14

programmes (Kjellby**-**Wendt et al., 2002).

for more than 2 hours a week.

OUTCOME MEASURE

Functional status OLBPDQ

Occupational activity,

Pain intesity

 F-EORS scale (% of normal)

**4. Summary** 

Depresion index, S-RDS scale

stabilization of the motor segments of the spine, improved posture and increased overall physical capacity of the body. The precise mechanism by which exercise alleviates pain has not been fully elucidated, although it may be associated with enhancing the nutrition status of the disc. Physical exercise, by stimulating changes in pressure within the intervertebral disc, may improve the mechanisms of osmosis that underlie disc nutrition.

The methodology of exercise attributes a significant role to strength- and endurancebuilding exercises. Muscle strength is of key importance for trunk stability. Augmentation of the spinal curvatures may be due to weakening of the paraspinal muscles. Epidemiologic studies have shown that patients with strong muscles less frequently complain of back pain. In healthy people, the extensor muscles of the trunk are stronger by 30% than the flexor muscles. However, it is believed that decreased strength is less important in back pain syndromes than decreased endurance capacity of dorsal and abdominal muscles (Davies et al., 1979; McGill**,** 1998).

Exercise accelerates repair and substitution processes in the musculoskeletal system and internal organs, and prevents the development of detrimental substitute motor patterns. It also prevents the development of secondary changes in bones, joints, muscles and ligaments and cardiorespiratory complications. The body's overall physical capacity is also improved. The main aim of exercises involving movement is to break the vicious circle of pain by reducing reflex increase in paraspinal muscle tension. Exercise also serves to improve stability of the lumbar spine by increasing intraabdominal pressure and restoring muscle balance, which prevents the recurrence of symptoms. Kinesiotherapy in low back pain should be well chosen and appropriately dosed. The notion of choice applies to exercise duration, the number of repetitions of an exercise and the duration of a series of exercises. The technique of therapeutic exercises is also important.

An exercise programme should begin with cycles of flexion and extension exercises serving to decrease stiffness and relax elastic structures. This will result in decreased load on the spinal joints during further exercises. The next batch of exercises should serve to improve mobility in the hip and knee joints and should be followed by exercises for the main spinal stabilisers, starting from abdominal muscles, with the spine in a neutral position throughout this stage. These, in turn, are followed by an ordered sequence of exercises in lateral support to strengthen the quadratus lumborum and oblique abdominis muscles, and exercises for the extensors spinae. The programme should be individualized with regard to the number of repetitions and duration of individual exercise items. The goals need to be clearly specified. Importantly, exercises should be performed in the pain-free range as much as possible. General fitness exercises should not be omitted from a programme for rehabilitation of low back pain sufferers (Nutter, 1988). A basic objective of the exercise set recommended by us is to restore normal static and dynamic balance and motor patterns. Improvement in motor function and alleviation of pain can often be observed following several months of exercises (Donchin et al., 1990 ; McGill**,** 1998). Of significance for LBP prevention is compliance with the principles of ergonomics during daily activities.(Zauner-Dungl et al., 2004))

#### **5. Conclusion**

The most important types of exercise for preventing low back pain are exercises for abdominal muscles, dorsal muscles, gluteal muscles and quadratus lumborum muscle. The

Exercises in Low Back Pain 259

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**1. Introduction** 

muscles.

**Lumbopelvic stabilization model** 

**Studies comparing Stability programs and others** 

**12** 

*Spain* 

**Stabilization Exercise for the** 

A. Luque-Suárez, E. Díaz-Mohedo,

 I. Medina-Porqueres and T. Ponce-García *Physiotherapy Department, Malaga University,* 

**Management of Low Back Pain** 

The lumbopelvic stabilization model is an active approach to low back pain, as proposed by Waddel (Waddel et al., 1997), based on a motor control exercises program. The main aim of this program is to reestablish the impairment or deficit in motor control around the neutral zone of the spinal motion segment by restoring the normal function of the local stabilizer

Stabilization exercise program has become the most popular treatment method in spinal rehabilitation since it has shown its effectiveness in some aspects related to pain and disability. However, some studies have reported that specific exercise program reduces pain and disability in chronic but not in acute low back pain, although it can be helpful in the

Despite stabilization exercises have become a major focus in spinal rehabilitation as well as in prophylactic care such as sports injury prevention (Zazulak et al., 2008), the therapeutic evidences in terms of postural control variables have not been well documented. Some randomized controlled trials have comprehensively reported the effects of core stability exercises versus conventional physiotherapy treatment regimes on pain characteristics, recurrence and disability scores in chronic low back pain patients emphasizing patient centered outcomes (Dankaerts et al., 2006; Liddle et al., 2007). These studies have addressed the need of homogenous chronic low back pain group for better clinical outcomes. Evaluating postural control parameters such as centre of pressure displacements, moments and forces following interventions, particularly stability exercises, may provide insight into how this surrogate outcomes are mediated by different subgroups or heterogeneous chronic low back pain patients and identifying subgroups of chronic low back pain patients who are

treatment of acute low back pain by reducing recurrence rate (Ferreira et al., 2006).

most likely to benefit after particular intervention (Muthukrishnan et al., 2010).

The core stability exercises cannot be superior to conventional physiotherapy exercises in terms of reducing pain and disability. However, core stability exercise demonstrates


## **Stabilization Exercise for the Management of Low Back Pain**

 A. Luque-Suárez, E. Díaz-Mohedo, I. Medina-Porqueres and T. Ponce-García *Physiotherapy Department, Malaga University, Spain* 

#### **1. Introduction**

260 Low Back Pain

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#### **Lumbopelvic stabilization model**

The lumbopelvic stabilization model is an active approach to low back pain, as proposed by Waddel (Waddel et al., 1997), based on a motor control exercises program. The main aim of this program is to reestablish the impairment or deficit in motor control around the neutral zone of the spinal motion segment by restoring the normal function of the local stabilizer muscles.

Stabilization exercise program has become the most popular treatment method in spinal rehabilitation since it has shown its effectiveness in some aspects related to pain and disability. However, some studies have reported that specific exercise program reduces pain and disability in chronic but not in acute low back pain, although it can be helpful in the treatment of acute low back pain by reducing recurrence rate (Ferreira et al., 2006).

#### **Studies comparing Stability programs and others**

Despite stabilization exercises have become a major focus in spinal rehabilitation as well as in prophylactic care such as sports injury prevention (Zazulak et al., 2008), the therapeutic evidences in terms of postural control variables have not been well documented. Some randomized controlled trials have comprehensively reported the effects of core stability exercises versus conventional physiotherapy treatment regimes on pain characteristics, recurrence and disability scores in chronic low back pain patients emphasizing patient centered outcomes (Dankaerts et al., 2006; Liddle et al., 2007). These studies have addressed the need of homogenous chronic low back pain group for better clinical outcomes. Evaluating postural control parameters such as centre of pressure displacements, moments and forces following interventions, particularly stability exercises, may provide insight into how this surrogate outcomes are mediated by different subgroups or heterogeneous chronic low back pain patients and identifying subgroups of chronic low back pain patients who are most likely to benefit after particular intervention (Muthukrishnan et al., 2010).

The core stability exercises cannot be superior to conventional physiotherapy exercises in terms of reducing pain and disability. However, core stability exercise demonstrates

Stabilization Exercise for the Management of Low Back Pain 263

Can be defined as "a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain" (Panjabi, 1992b). Therefore, an unstable spinal segment might not be able to maintain the correct vertebral alignment. The excessive movement in an unstable spine may either stretch

It is also necessary to differentiate between instability and hypermobility because in both cases the range of motion is greater than normal. The main difference is that hypermobility might be asymptomatic, however, instability exits when dysfunctions, which can induce

Panjabi conceptualized the basis of the stabilization system of the spine, subdividing it into three different subsystems: the active subsystem, the passive subsystem and the control

**The Passive subsystem** consists on the ligamentous system and does not generate or produce itself any motion at the spine. It produces reactive forces by the end of the ranges of motion but its prime assignment is to work as a signals transducer to the neural subsystem and to send any sense of vertebral position or motion, especially those produced by the

**The Active subsystem** is composed of muscles and tendons which generate forces to supply the stability to the spine (Panjabi, 1992a). Poor postural control can leave the spine vulnerable to injury by placing excessive stress on the body tissues (Kendall et al., 1993). In the lumbar spine, the trunk muscles protect spinal tissues from excessive motion. To do this, however, the muscle surrounding the trunk must be able to co-contract isometrically when appropriate (Richardson, 1990). The synergistic interaction between various trunk muscles is complex: some muscles act as primary movers to create the gross movements of the trunk, whereas others function as stabilizers (fixators) and neutralizers to support the spinal structures and control unwanted movements. Rehabilitation through active lumbar stabilization not only deals with the torque- producing capacity of muscles, as it is true for many traditional programs, but also seeks to enable a person to unconsciously and consistently coordinate an optimal pattern of muscle activity (Jull&Richardson, 1994a).

**The Neural Control subsystem**. Its function is to receive all the sensory feedback from the transducers of the passive system, determine the stability requirements and make the active system to achieve those stability goals. It also has an important role in measuring the forces generated in each muscle through the transducers located inside the tendons (Panjabi, 1992). In a normal situation, the stabilization system provides the stability required to fulfill the demands of the constantly changing stability provoked by variations in posture and static and dynamic loads. To meet all those needs, the three subsystems must work together in harmony. However, dysfunction of any of these three components might incite a fail in the

whole system, leading, over time, to chronic dysfunction and pain (Panjabi, 1992a).

or compress pain sensitive structures, leading to inflammation (Panjabi, 1992a).

pain while performing active physiological movements (Paris, 1985).

**Spinal instability. Panjabi's Hypotheses** 

**1.1 The stabilization system of the spine** 

vicinity of the neutral zone (Panjabi, 1992a).

subsystem.

significant improvements in: distribution of ground reaction forces, use of optimized postural adjustments in the direction of perturbation, 20% absolute risk reduction of flare-up during intervention and 40% absolute risk reduction for resolution of back pain after core instability exercises (Muthukrishnan et al., 2010).

Core stability exercise is an evolving process, and refinement of the clinical rehabilitation strategies is ongoing. Further work is required, however, to refine and validate the approach, particularly with reference to contemporary understanding of the neurobiology of chronic pain (Hodges, 2003).

Related to the comparison between Pilates method and stabilization programs, Pilates method did not improve functionality and pain in patients who have low back pain when compared with control and lumbar stabilization exercise groups (Pereira et al., 2011).

To contrast the efficacy of two exercise programs, segmental stabilization and strengthening of abdominal and trunk muscles, on pain, functional disability, and activation of the transversus abdominis (TrA) muscle, in individuals with chronic low back pain. Both techniques lessened pain and reduced disability. Segmental stabilization is superior to superficial strengthening for all variables. Superficial strengthening does not improve TrA activation capacity (Franca et al., 2011).

Comparing traditional exercise program and core stabilization program one group of Soldiers (N = 2616) between 18 and 35 years of age were randomized to receive a traditional exercise program (TEP) with sit-ups or Core Stabilization exercise program (CSEP). CSEP did not have a detrimental impact on sit-up performance or overall fitness scores or pass rates. There was a small but significantly greater increase in sit-up pass rate in the CSEP (5.6%) versus the TEP group (3.9%) (Childs et al., 2009).

#### **Who is suitable for getting benefits from a stabilization program?**

This sort of program has shown to produce short-term improvements in global impression of recovery and activity for people with chronic low back pain, maintaining the results after 6 and 12 months (Costa et al., 2009), as well as be superior to minimal intervention at long term follow-up (Macedo et al., 2009; Kriese, 2010). Improvements in pain intensity and functional disability were also demonstrated in groups of patients with low back pain suffering from a spondylolisis or a spondylolisthesis (O'Sullivan, 2000) and a significant decrease of symptoms in people with hypermobility (Fritz et al., 2005).

However, before approaching this model, for better understanding the theory basis some of the crucial terms will be described.

#### **Neutral Position**

"The posture of the spine in which the overall internal stresses in the spinal column and muscular effort to hold the posture are minimal" (Panjabi, 1992b)

#### **Neutral Zone**

"That part of the physiological intervertebral motion, measured from the neutral position, within which the spinal motion is produced with a minimal internal resistance. It is the zone of high flexibility or laxity" (Panjabi, 1992b).

#### **Spinal instability. Panjabi's Hypotheses**

262 Low Back Pain

significant improvements in: distribution of ground reaction forces, use of optimized postural adjustments in the direction of perturbation, 20% absolute risk reduction of flare-up during intervention and 40% absolute risk reduction for resolution of back pain after core

Core stability exercise is an evolving process, and refinement of the clinical rehabilitation strategies is ongoing. Further work is required, however, to refine and validate the approach, particularly with reference to contemporary understanding of the neurobiology

Related to the comparison between Pilates method and stabilization programs, Pilates method did not improve functionality and pain in patients who have low back pain when

To contrast the efficacy of two exercise programs, segmental stabilization and strengthening of abdominal and trunk muscles, on pain, functional disability, and activation of the transversus abdominis (TrA) muscle, in individuals with chronic low back pain. Both techniques lessened pain and reduced disability. Segmental stabilization is superior to superficial strengthening for all variables. Superficial strengthening does not improve TrA

Comparing traditional exercise program and core stabilization program one group of Soldiers (N = 2616) between 18 and 35 years of age were randomized to receive a traditional exercise program (TEP) with sit-ups or Core Stabilization exercise program (CSEP). CSEP did not have a detrimental impact on sit-up performance or overall fitness scores or pass rates. There was a small but significantly greater increase in sit-up pass rate in the CSEP

This sort of program has shown to produce short-term improvements in global impression of recovery and activity for people with chronic low back pain, maintaining the results after 6 and 12 months (Costa et al., 2009), as well as be superior to minimal intervention at long term follow-up (Macedo et al., 2009; Kriese, 2010). Improvements in pain intensity and functional disability were also demonstrated in groups of patients with low back pain suffering from a spondylolisis or a spondylolisthesis (O'Sullivan, 2000) and a significant

However, before approaching this model, for better understanding the theory basis some of

"The posture of the spine in which the overall internal stresses in the spinal column and

"That part of the physiological intervertebral motion, measured from the neutral position, within which the spinal motion is produced with a minimal internal resistance. It is the zone

compared with control and lumbar stabilization exercise groups (Pereira et al., 2011).

instability exercises (Muthukrishnan et al., 2010).

of chronic pain (Hodges, 2003).

activation capacity (Franca et al., 2011).

the crucial terms will be described.

of high flexibility or laxity" (Panjabi, 1992b).

**Neutral Position** 

**Neutral Zone** 

(5.6%) versus the TEP group (3.9%) (Childs et al., 2009).

**Who is suitable for getting benefits from a stabilization program?** 

decrease of symptoms in people with hypermobility (Fritz et al., 2005).

muscular effort to hold the posture are minimal" (Panjabi, 1992b)

Can be defined as "a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain" (Panjabi, 1992b). Therefore, an unstable spinal segment might not be able to maintain the correct vertebral alignment. The excessive movement in an unstable spine may either stretch or compress pain sensitive structures, leading to inflammation (Panjabi, 1992a).

It is also necessary to differentiate between instability and hypermobility because in both cases the range of motion is greater than normal. The main difference is that hypermobility might be asymptomatic, however, instability exits when dysfunctions, which can induce pain while performing active physiological movements (Paris, 1985).

#### **1.1 The stabilization system of the spine**

Panjabi conceptualized the basis of the stabilization system of the spine, subdividing it into three different subsystems: the active subsystem, the passive subsystem and the control subsystem.

**The Passive subsystem** consists on the ligamentous system and does not generate or produce itself any motion at the spine. It produces reactive forces by the end of the ranges of motion but its prime assignment is to work as a signals transducer to the neural subsystem and to send any sense of vertebral position or motion, especially those produced by the vicinity of the neutral zone (Panjabi, 1992a).

**The Active subsystem** is composed of muscles and tendons which generate forces to supply the stability to the spine (Panjabi, 1992a). Poor postural control can leave the spine vulnerable to injury by placing excessive stress on the body tissues (Kendall et al., 1993). In the lumbar spine, the trunk muscles protect spinal tissues from excessive motion. To do this, however, the muscle surrounding the trunk must be able to co-contract isometrically when appropriate (Richardson, 1990). The synergistic interaction between various trunk muscles is complex: some muscles act as primary movers to create the gross movements of the trunk, whereas others function as stabilizers (fixators) and neutralizers to support the spinal structures and control unwanted movements. Rehabilitation through active lumbar stabilization not only deals with the torque- producing capacity of muscles, as it is true for many traditional programs, but also seeks to enable a person to unconsciously and consistently coordinate an optimal pattern of muscle activity (Jull&Richardson, 1994a).

**The Neural Control subsystem**. Its function is to receive all the sensory feedback from the transducers of the passive system, determine the stability requirements and make the active system to achieve those stability goals. It also has an important role in measuring the forces generated in each muscle through the transducers located inside the tendons (Panjabi, 1992).

In a normal situation, the stabilization system provides the stability required to fulfill the demands of the constantly changing stability provoked by variations in posture and static and dynamic loads. To meet all those needs, the three subsystems must work together in harmony. However, dysfunction of any of these three components might incite a fail in the whole system, leading, over time, to chronic dysfunction and pain (Panjabi, 1992a).

Stabilization Exercise for the Management of Low Back Pain 265

2006). Nevertheless, it has been reported some good results in recovering these changes with

**Mobilizers**: are superficial and are often biarticular (two-joint) muscles. They can develop angular rotation more effectively than the stabilizers. This group of muscles acts as stabilizers only in conditions of extreme need. When they do, the precision of movement is

Build tension slowly, more fatigue

Better activated at low levels of

More effective in closed chain

 In muscle imbalance, tend to weaken and lenghten

Build tension rapidly, fatigue

More effective in open chain

 In muscle imbalance, tend to tighten and shorten

Better activated at high levels of

quickly

resistance

movements

In this table, stabilizer and mobilizer muscles that affect the low back are presented. Muscles

resistant

resistance

movement

a specific stabilization program (Hides et al., 1996; Hides et al., 2008).

In table 1 we can see stabilizers and mobilizers characteristics (Norris, 2008).

often lost, creating and observable movement dysfunction.

 Deep, close to joint Slow twitch

(1joint)

Short fibers

Slow twitch

Fast twitch

Table 1. Stabilizers and mobilizers characteristics.

with (\*) can work in different ways.

Usually monoarticular

No significant torque

 Usually monoarticular Primary source of torque

 Often biarticular (2 joints) Secondary source of torque

Secondary stabilizers: Intermediate depth

 Attachments are multipennate

Stabilizers Primary stabilizers:

Mobilizers Superficial

Each of these three interrelated systems has its own role in maintaining the spinal stability. Inert tissues (in particular ligaments) provide passive support; contractile tissues give active support; and neural control centers links the passive and active systems, receives information about the position and direction of the movements and coordinates and control the muscles ability to contract and maintain stability (i.e., to increase stiffness and reduce the size of the neutral zone). This will depend on the speed and accuracy with which the information is relayed. The vital aspects of neural system development are therefore accuracy of movement and speed of reaction. Thus, the stabilization program emphasizes accuracy of movements early on; speed comes later.

Generally speaking, the main strategy of the stabilization model is to reduce the size of the neutral zone by increasing stiffness offered by muscles contraction (Norris, 2008)

Following with the Stabilization model, we are focusing now on the active support system. In this concept we must avoid *muscle imbalance* that occurs when one muscle, the "agonist", is stronger than the opposite, the "antagonist", or when one or the other is abnormally shortened or lengthened.

#### **1.2 Types of muscles**

We can categorize muscles into two groups: stabilizers or "postural muscles" and mobilizers or "task muscles" (Janda&Schmid, 1980; Richardson, 1990).

**Stabilizers or postural muscles**: stabilize a joint and approximate the joint surfaces. Tend to be more deeply placed in the body and are usually monoarticular muscles. Stabilizers can be subdivided into primary and secondary types (Jull&Richardson, 1994). Many of these smaller muscles have and important proprioceptive functions. For example, the intertransversarii muscles of the lumbar spine and the interspinals muscles both have a dense concentration of muscle spindles indicating a significant proprioceptive function (Adams et al., 2002). Intertransversarii muscles and interspinals muscles have demonstrated their influence over low back pain. The secondary stabilizers are the main torque producers, being large monoarticular muscles attaching via extensive aponeurosis.

Despite there is no actual evidence whether pain or motor control impairments come first, Panjabi (1992a) suggested that changes in the active support system might lead to a poor control of the joints and repeated microtrauma and pain. Supporting this idea, many research works have been conducted to explain all those fails in controlling the stability of the spine. According to this, changes in automatic control of TrA have been found in people with low back pain (Ferreira et al., 2004), a delayed onset of its contraction (Hodges&Richardson, 1996) and a loss of its tonic and preadjusting function (Hodges, 1999), what indicates a motor control deficit and is hypothesized to result in inefficient muscular stabilization of the spine (Hodges, 1996, 1999). The activation of the other stabilizer muscles also appears delayed, but to a lesser extent (Hodges, 1999).

On the other hand, there are many research papers about the changes that occur in other stabilizers as a consequence of or associated to chronic low back pain. Some of these changes are: a reduction in the cross-sectional areas of multifidus, psoas, and quadratus lumborum (Kamaz et al., 2007), asymmetric atrophy between both side of the symptomatic level (Hides et al., 2006) and fat infiltrations in multifidus muscles (Kjaer et al., 2006; Mengiardi et al.,

Each of these three interrelated systems has its own role in maintaining the spinal stability. Inert tissues (in particular ligaments) provide passive support; contractile tissues give active support; and neural control centers links the passive and active systems, receives information about the position and direction of the movements and coordinates and control the muscles ability to contract and maintain stability (i.e., to increase stiffness and reduce the size of the neutral zone). This will depend on the speed and accuracy with which the information is relayed. The vital aspects of neural system development are therefore accuracy of movement and speed of reaction. Thus, the stabilization program emphasizes

Generally speaking, the main strategy of the stabilization model is to reduce the size of the

Following with the Stabilization model, we are focusing now on the active support system. In this concept we must avoid *muscle imbalance* that occurs when one muscle, the "agonist", is stronger than the opposite, the "antagonist", or when one or the other is abnormally

We can categorize muscles into two groups: stabilizers or "postural muscles" and mobilizers

**Stabilizers or postural muscles**: stabilize a joint and approximate the joint surfaces. Tend to be more deeply placed in the body and are usually monoarticular muscles. Stabilizers can be subdivided into primary and secondary types (Jull&Richardson, 1994). Many of these smaller muscles have and important proprioceptive functions. For example, the intertransversarii muscles of the lumbar spine and the interspinals muscles both have a dense concentration of muscle spindles indicating a significant proprioceptive function (Adams et al., 2002). Intertransversarii muscles and interspinals muscles have demonstrated their influence over low back pain. The secondary stabilizers are the main torque producers,

Despite there is no actual evidence whether pain or motor control impairments come first, Panjabi (1992a) suggested that changes in the active support system might lead to a poor control of the joints and repeated microtrauma and pain. Supporting this idea, many research works have been conducted to explain all those fails in controlling the stability of the spine. According to this, changes in automatic control of TrA have been found in people with low back pain (Ferreira et al., 2004), a delayed onset of its contraction (Hodges&Richardson, 1996) and a loss of its tonic and preadjusting function (Hodges, 1999), what indicates a motor control deficit and is hypothesized to result in inefficient muscular stabilization of the spine (Hodges, 1996, 1999). The activation of the other stabilizer muscles

On the other hand, there are many research papers about the changes that occur in other stabilizers as a consequence of or associated to chronic low back pain. Some of these changes are: a reduction in the cross-sectional areas of multifidus, psoas, and quadratus lumborum (Kamaz et al., 2007), asymmetric atrophy between both side of the symptomatic level (Hides et al., 2006) and fat infiltrations in multifidus muscles (Kjaer et al., 2006; Mengiardi et al.,

neutral zone by increasing stiffness offered by muscles contraction (Norris, 2008)

accuracy of movements early on; speed comes later.

or "task muscles" (Janda&Schmid, 1980; Richardson, 1990).

also appears delayed, but to a lesser extent (Hodges, 1999).

being large monoarticular muscles attaching via extensive aponeurosis.

shortened or lengthened.

**1.2 Types of muscles** 

2006). Nevertheless, it has been reported some good results in recovering these changes with a specific stabilization program (Hides et al., 1996; Hides et al., 2008).

**Mobilizers**: are superficial and are often biarticular (two-joint) muscles. They can develop angular rotation more effectively than the stabilizers. This group of muscles acts as stabilizers only in conditions of extreme need. When they do, the precision of movement is often lost, creating and observable movement dysfunction.

In table 1 we can see stabilizers and mobilizers characteristics (Norris, 2008).


Table 1. Stabilizers and mobilizers characteristics.

In this table, stabilizer and mobilizer muscles that affect the low back are presented. Muscles with (\*) can work in different ways.

Stabilization Exercise for the Management of Low Back Pain 267

On the other hand, tightness and weakness in muscle imbalance alters body segment alignment and changes the equilibrium point of a point. If the muscles on one side of a joint are tight and the opposing muscles are lax, the joint will be pull out alignment toward the tight muscle. This alteration in alignment throws weight-bearing stress out a smaller region of the point surface, increasing pressure per unit area. Furthermore, the inert tissues on the

The combination of stiffness (hypoflexibility) in one body segment and laxity (hyperflexibility) in an adjacent segment leads to the development of relative flexibility

In contrast, radiologists have tried to determine the intervertebral instability using imaging techniques to assess both normal and abnormal ranges of movements. Most common techniques used to measure those intervertebral ranges of movements are neutral radiographs and functional in both flexion and extension taken in sagittal plane (Alam, 2002; Leone et al, 2007). Some of the measurements taken by many authors in different studies are

> **Translation (mm)**

> > 2-3 3

> > > 3 3

> > > 3 3

**Rotation (degrees)** 

> 7-13 14

> > 13 20

> > 9 17

shortened (closed) side of the joint will contract over time.

**Author Spinal** 

Hayes et al. L1-5

White et al. L1-5

Froming & Frohman L1-5

Sagittal plane translation > 4.5 mm or 15%

Sagittal plane displacement >4.5 mm or 15%

Relative sagittal plane angulation >22º

instability are the following: Flexion–extension radiographs

 Sagittal plane rotation 15º at L1-2, L2-3, and L3-4

**Resting radiographs** 

20º at L4-5 25º at L5-S1 **Level** 

L5-S1

L5-S1

L5-S1

Kanayama et al. L1-5 4 10

Table 3. The upper limits of motion in a normal spine as seen on functional radiography.

According to White and Panjabi (1978), the radiographic criteria established as spinal

Despite this measurements techniques are commonly used in taking care of some spinal pathologies, especially degenerative disorders, are not really relevant in clinical practice

(White&Sahrmann, 1994).

shown in the table below.


Table 2. Stabilizer and mobilizer muscles that affect the low back

#### **2. Diagnosis in lumbopelvic stabilization model**

The main purpose of our diagnosis is to identify the abnormal segmental control of a motion segment. For that assessment, passive intervertebral manual pressures directly applied on the spinous process can be utilized in the search of an excessive or uncontrolled segmental translation. Usually, the application of that force on an affected or unstable segment may provoke pain or reproduce the symptoms. Multifidus muscles atrophy at any level could be another sign to detect a dysfunctional spinal segment. This can be assessed by palpation at both sides of the spinous process of every level and might be either unilateral or bilateral (figure 12).

Referring movement impairment changes in body segment alignment and the degree of segmental control (the ability to move one body segment without moving any others) form the basis of the movement impairment tests.

Rectus femoris

External oblique Quadratus lumborum \*

Levator scapulae

Pectoralis minor Pectoralis major

Scalenes

STABILIZERS MOBILIZERS

Multifidus Gluteus maximus Iliopsoas \*

Transversus abdominis Quadriceps Hamstrings

Internal oblique Iliopsoas \* Tensor fasciae lata

Serratus anterior Upper trapezius Rectus abdominis

Lower trapezius Quadratus lumborum \* Erector spinae

Deep neck flexors Upper trapezius

Sternomastoid

Rhomboids

The main purpose of our diagnosis is to identify the abnormal segmental control of a motion segment. For that assessment, passive intervertebral manual pressures directly applied on the spinous process can be utilized in the search of an excessive or uncontrolled segmental translation. Usually, the application of that force on an affected or unstable segment may provoke pain or reproduce the symptoms. Multifidus muscles atrophy at any level could be another sign to detect a dysfunctional spinal segment. This can be assessed by palpation at both sides of the spinous process of every level and might be either unilateral or bilateral

Referring movement impairment changes in body segment alignment and the degree of segmental control (the ability to move one body segment without moving any others) form

Table 2. Stabilizer and mobilizer muscles that affect the low back

**2. Diagnosis in lumbopelvic stabilization model**

the basis of the movement impairment tests.

(figure 12).

Gluteus medius Subscapularis Hip adductors

Vastusmedialis Infraspinatus Piriformis

Primary Secondary

On the other hand, tightness and weakness in muscle imbalance alters body segment alignment and changes the equilibrium point of a point. If the muscles on one side of a joint are tight and the opposing muscles are lax, the joint will be pull out alignment toward the tight muscle. This alteration in alignment throws weight-bearing stress out a smaller region of the point surface, increasing pressure per unit area. Furthermore, the inert tissues on the shortened (closed) side of the joint will contract over time.

The combination of stiffness (hypoflexibility) in one body segment and laxity (hyperflexibility) in an adjacent segment leads to the development of relative flexibility (White&Sahrmann, 1994).

In contrast, radiologists have tried to determine the intervertebral instability using imaging techniques to assess both normal and abnormal ranges of movements. Most common techniques used to measure those intervertebral ranges of movements are neutral radiographs and functional in both flexion and extension taken in sagittal plane (Alam, 2002; Leone et al, 2007). Some of the measurements taken by many authors in different studies are shown in the table below.


Table 3. The upper limits of motion in a normal spine as seen on functional radiography.

According to White and Panjabi (1978), the radiographic criteria established as spinal instability are the following:

Flexion–extension radiographs


15º at L1-2, L2-3, and L3-4

20º at L4-5

25º at L5-S1

#### **Resting radiographs**


Despite this measurements techniques are commonly used in taking care of some spinal pathologies, especially degenerative disorders, are not really relevant in clinical practice

Stabilization Exercise for the Management of Low Back Pain 269

Fig. 3(b) Thomas test (iliopsoas shortened).

Fig. 3(c). Modified Thomas test (rectus femoris shortened).

Goal: to assess the length of tensor fasciae lata muscle.

homolateral leg to the level of the table.

The patient adopts a side-lying position with the pelvis in neutral. Contralateral knee is bent in order to improve overall body stability while the examiner stabilizes the pelvis to avoid lateral pelvic dipping. Patient abducts the homolateral leg to 15º above the horizontal and then extends his hip about 15º. While maintaining extension patient is then told to adduct his/her leg. Optimal muscle length would be confirmed if he/she is able to lower the

**2.1.2 Ober Test** 

when talking about stabilization exercise program and its used as an instability evaluation technique has not been reported in any of the stabilization research papers.

Now some examples of different tests related to tight muscles, lax muscles and movement impaired are presented.

#### **2.1 Tight muscles tests**

#### **2.1.1 Thomas test**

Goal: to assess the length of the hip flexors.

The patient begins in supine position on the examination table. He/she is told to lift both knees up to his/her chest, keeping his/her back flattened to a point where the sacrum just begins to lift away from the examination table surface, but not further. As he holds on leg close to his chest in order to maintain the pelvic position, the opposite lower limb is gradually extended until it rests on the table. An increase of lumbar lordosis or the impossibility to complete the knee extension (figure 3b) indicates shortened hip flexors (iliopsoas mainly).

The same procedure with the examined leg out of the table (figure 3c) elucidates a shortened rectus femoris. Optimal alignment occurs with the femur horizontal and aligned with the sagittal plane (no abduction) and with the subject's shoulder, hip, and knee more or less in line. A positive test is indicated when the tibia loses their vertical position due to knee extension. The test is negative when the tibia remains vertical.

Fig. 3(a). Thomas test (no shortness).

when talking about stabilization exercise program and its used as an instability evaluation

Now some examples of different tests related to tight muscles, lax muscles and movement

The patient begins in supine position on the examination table. He/she is told to lift both knees up to his/her chest, keeping his/her back flattened to a point where the sacrum just begins to lift away from the examination table surface, but not further. As he holds on leg close to his chest in order to maintain the pelvic position, the opposite lower limb is gradually extended until it rests on the table. An increase of lumbar lordosis or the impossibility to complete the knee extension (figure 3b) indicates shortened hip flexors

The same procedure with the examined leg out of the table (figure 3c) elucidates a shortened rectus femoris. Optimal alignment occurs with the femur horizontal and aligned with the sagittal plane (no abduction) and with the subject's shoulder, hip, and knee more or less in line. A positive test is indicated when the tibia loses their vertical position due to knee

technique has not been reported in any of the stabilization research papers.

impaired are presented.

**2.1 Tight muscles tests** 

Goal: to assess the length of the hip flexors.

Fig. 3(a). Thomas test (no shortness).

extension. The test is negative when the tibia remains vertical.

**2.1.1 Thomas test** 

(iliopsoas mainly).

Fig. 3(b) Thomas test (iliopsoas shortened).

Fig. 3(c). Modified Thomas test (rectus femoris shortened).

#### **2.1.2 Ober Test**

Goal: to assess the length of tensor fasciae lata muscle.

The patient adopts a side-lying position with the pelvis in neutral. Contralateral knee is bent in order to improve overall body stability while the examiner stabilizes the pelvis to avoid lateral pelvic dipping. Patient abducts the homolateral leg to 15º above the horizontal and then extends his hip about 15º. While maintaining extension patient is then told to adduct his/her leg. Optimal muscle length would be confirmed if he/she is able to lower the homolateral leg to the level of the table.

Stabilization Exercise for the Management of Low Back Pain 271

Goal: to determine if the gluteus medius muscle is capable of holding the hip in full inner-

Fig. 6(a). Assessing muscle balance in the gluteus medius; started position.

Fig. 5. Straight-leg raise test.

**2.2.1 Assessing muscle balance in the gluteus medius** 

range combined abduction and external rotation.

**2.2 Lax muscles tests** 

Fig. 4(a). Ober test; started position.

Fig. 4(b). Ober test; ended position.

#### **2.1.3 Straight-leg raise test**

Goal: to assess tightness in hamstrings.

The patient lies supine on the examination table, with one leg slightly bent. The patient is told to raise the other leg, keeping it completely straight. The examiner palpates the anterior rim of the pelvis to note the point at which the pelvis begins to posteriorly tilt because of hamstrings tightness. Optimal muscle length will permit degrees of flexion around 60-70º.

Fig. 5. Straight-leg raise test.

#### **2.2 Lax muscles tests**

270 Low Back Pain

The patient lies supine on the examination table, with one leg slightly bent. The patient is told to raise the other leg, keeping it completely straight. The examiner palpates the anterior rim of the pelvis to note the point at which the pelvis begins to posteriorly tilt because of hamstrings tightness. Optimal muscle length will permit degrees of flexion around 60-70º.

Fig. 4(a). Ober test; started position.

Fig. 4(b). Ober test; ended position.

Goal: to assess tightness in hamstrings.

**2.1.3 Straight-leg raise test** 

#### **2.2.1 Assessing muscle balance in the gluteus medius**

Goal: to determine if the gluteus medius muscle is capable of holding the hip in full innerrange combined abduction and external rotation.

Fig. 6(a). Assessing muscle balance in the gluteus medius; started position.

Stabilization Exercise for the Management of Low Back Pain 273

The test consists in measuring the amount of time a person can hold the unsupported upper body in a horizontal prone position with the lower body fixed to the examining table.

With the patient lying prone, a pressure biofeedback unit is placed under his/her abdomen with the upper edge of the device's bladder below his navel. The unit is then inflated to 70 mmHg and patient is instructed to perform the abdominal hollowing maneuver. The aim is to reduce the pressure reading on the biofeedback unit by 6 to 10 mmHg and to maintain

Maximum values:

Healthy women: 171 sec. Healthy men: 239 sec.

Low back pain women: 99 sec. Low back pain men: 109 sec.

**2.2.3 Prone abdominal hollowing test using pressure biofeedback** 

Goal: to assess patient's ability to hold the inner range of the deep abdominals.

this contraction for 10 repetitions of 10 sec. each while breathing normally.

Fig. 8. Prone abdominal hollowing test using pressure biofeedback.

Goal: to determine the quality of each movement (flexion, extension, side-bending and

Patient stands up and is asked to move into flexion, extension, side-bending and rotation.

Goal: to determine control of the hip relative to the lumbar-pelvic region while kneeling.

Pelvis and low back is monitored any time in a quantitative and qualitative way.

**2.3 Movement impaired test** 

**2.3.2 Kneeling rock-back** 

rotation).

**2.3.1 Functional low back movements** 

The action in this test combines hip abduction and slight lateral rotation to emphasize the posterior fibers of the muscle. Patient lies on one side with his knees flexed and feet together. This position will identify where muscle tone is poor. People should rotate their trunk forward until the chest is on the couch and allow the knee to drop over the couch side. From this position they lift the leg as before.

Fig. 6(b). Assessing muscle balance in the gluteus medius; ended position.

#### **2.2.2 Sorensen test (low back fatigue test)**

Goal: to determine isometric endurance of trunk extensor muscles.

Fig. 7. Sorensen test.

The test consists in measuring the amount of time a person can hold the unsupported upper body in a horizontal prone position with the lower body fixed to the examining table.

Maximum values:

272 Low Back Pain

The action in this test combines hip abduction and slight lateral rotation to emphasize the posterior fibers of the muscle. Patient lies on one side with his knees flexed and feet together. This position will identify where muscle tone is poor. People should rotate their trunk forward until the chest is on the couch and allow the knee to drop over the couch side.

Fig. 6(b). Assessing muscle balance in the gluteus medius; ended position.

Goal: to determine isometric endurance of trunk extensor muscles.

From this position they lift the leg as before.

**2.2.2 Sorensen test (low back fatigue test)** 

Fig. 7. Sorensen test.

Healthy women: 171 sec. Healthy men: 239 sec.

Low back pain women: 99 sec. Low back pain men: 109 sec.

#### **2.2.3 Prone abdominal hollowing test using pressure biofeedback**

Goal: to assess patient's ability to hold the inner range of the deep abdominals.

With the patient lying prone, a pressure biofeedback unit is placed under his/her abdomen with the upper edge of the device's bladder below his navel. The unit is then inflated to 70 mmHg and patient is instructed to perform the abdominal hollowing maneuver. The aim is to reduce the pressure reading on the biofeedback unit by 6 to 10 mmHg and to maintain this contraction for 10 repetitions of 10 sec. each while breathing normally.

Fig. 8. Prone abdominal hollowing test using pressure biofeedback.

#### **2.3 Movement impaired test**

#### **2.3.1 Functional low back movements**

Goal: to determine the quality of each movement (flexion, extension, side-bending and rotation).

Patient stands up and is asked to move into flexion, extension, side-bending and rotation. Pelvis and low back is monitored any time in a quantitative and qualitative way.

#### **2.3.2 Kneeling rock-back**

Goal: to determine control of the hip relative to the lumbar-pelvic region while kneeling.

Stabilization Exercise for the Management of Low Back Pain 275

Patient stands side-on to a wall with one hand on the wall for balance if needed. He/she is instructed to slowly lift one leg, with the knee bent. The leg should reach a comfortable position -usually above hip height- and then lower. The examiner monitors the lumbarpelvic region from the front and the side. In optimal alignment, the pelvis should remain level horizontally as the patient lifts his leg, and the sequence should be hip motion (flexion) followed by pelvic motion (posterior tilt) followed by lumbar motion -lordosis flattens and then reverses-. Poor control exits when the pelvis drops as the leg is lifted, and the lumbar

Goal: to assess lumbar-pelvic control during one-leg lifting.

spine flexes during the early stages of the movement.

**2.3.3 One-leg lift** 

Fig. 10. One-leg lift.

**2.3.4 Forward bending** 

Goal: to determine lumbar-pelvic control in bending.

Patient is kneeling on a mat on all fours, with his/her hand directly beneath his shoulder and his knee beneath his hip. The test begins with the lumbar spine in a neutral position and then is rocked backward, pulling the hip behind the knees. Examiner should monitor the pelvic tilt angle and lumbar lordosis. Motion should begin at the hip for an optimal segmental control. Once hip flexion passes about 120º (depending on patient´s body proportions), his pelvis should posteriorly tilt and his lumbar spine flatten. Examiner should ensure that he moves slowly, and determine whether the sequence is motion at the hippelvis-lumbar spine. Poor segmental control will be present if the pelvic tilts and the lumbar spine flattens at the beginning of the rock-back.

Fig. 9(a). Kneeling rock-back; starting position.

Fig. 9(b). Kneeling rock-back; ended position.

#### **2.3.3 One-leg lift**

274 Low Back Pain

Patient is kneeling on a mat on all fours, with his/her hand directly beneath his shoulder and his knee beneath his hip. The test begins with the lumbar spine in a neutral position and then is rocked backward, pulling the hip behind the knees. Examiner should monitor the pelvic tilt angle and lumbar lordosis. Motion should begin at the hip for an optimal segmental control. Once hip flexion passes about 120º (depending on patient´s body proportions), his pelvis should posteriorly tilt and his lumbar spine flatten. Examiner should ensure that he moves slowly, and determine whether the sequence is motion at the hippelvis-lumbar spine. Poor segmental control will be present if the pelvic tilts and the lumbar

spine flattens at the beginning of the rock-back.

Fig. 9(a). Kneeling rock-back; starting position.

Fig. 9(b). Kneeling rock-back; ended position.

Goal: to assess lumbar-pelvic control during one-leg lifting.

Patient stands side-on to a wall with one hand on the wall for balance if needed. He/she is instructed to slowly lift one leg, with the knee bent. The leg should reach a comfortable position -usually above hip height- and then lower. The examiner monitors the lumbarpelvic region from the front and the side. In optimal alignment, the pelvis should remain level horizontally as the patient lifts his leg, and the sequence should be hip motion (flexion) followed by pelvic motion (posterior tilt) followed by lumbar motion -lordosis flattens and then reverses-. Poor control exits when the pelvis drops as the leg is lifted, and the lumbar spine flexes during the early stages of the movement.

Fig. 10. One-leg lift.

#### **2.3.4 Forward bending**

Goal: to determine lumbar-pelvic control in bending.

region.

Stabilization Exercise for the Management of Low Back Pain 277

give essential information about joint protection mechanisms, especially in the lumbopelvic

Lumbopelvic stabilization program needs to involve a problem-solving approach, where clinical tests, reflecting the dysfunction mechanisms, are used to decide the best type of treatment approach for an individual client. In order to achieve this, assessments and their related treatments have been simplified by dividing them into progressive stages, where one stage of assessment and treatment is ideally completed prior to proceeding to the next stage. The segmental approach we have devised develops through three stages of segmental control, with each stage exposing the individual patient to increasing challenges to his/her

Segmental control over primary stabilizers (mainly TrA, deep multifidus, pelvic floor

We refer to re-establishing directly the simultaneous contraction of the deep muscle synergy independently of the secondary stabilizers and mobilizers. This simultaneous contraction of the synergy, independent of the global muscles, should occur with the postural cue to "draw in the abdominal wall". The weight of the body is minimized in order to allow the patient to

Training local segmental control involves activating and facilitating the local muscle system, while using techniques (e.g. feedback) to reduce the contribution of the global muscles, most particularly the mobilizers. Instructional cues, body position and various feedback techniques (including palpation, electromyography and real-time ultrasound) are used simultaneously to facilitate the local synergy and inhibit or relax the more active global muscles. The ability to hold this pattern through developing specific muscular control, without addition of any load, may serve also to help to restore kinaesthetic awareness and lumbopelvic position sense, usually found to be impaired in the patient with low back pain. The precise position of the lumbopelvic region may itself be facilitatory for activation of the local synergy muscles. Recent research has shown that better co-activation of the TrA occurs when the pelvic floor is contracted with the lumbar spine place in a more neutral position (Sapsford et al., 1997b). There is a consensus that local muscles are involved in segmental support and, therefore, contribute to the precise positioning of the lumbosacral

In order to get a suitable activation of lumbar multifidus (LM), a submaximal contraction was elicited with the contralateral arm lift maneuver, while holding a small hand weight, as previously demonstrated to elicit approximately 30% of the maximal voluntary contraction

joint protection mechanisms (Richardson et al., 2004).

Key: Segmental control over primary stabilizers.

focus on this specific skill involved in joint protection.

 Exercises in closed chain, with low velocity and low load Exercises in open chain, with high velocity and load

and diaphragm)

**3.1 Phase 1** 

curve.

**Lumbar multifidus activation** 

of the LM muscle (Koppenhaver et al., 2011).

Patient stands with his/her feet shoulder-width apart, facing the seat of a chair. He/she is instructed to bend forward, to touch the chair seat, and to stand back up again. Optimal control occurs when the patient unlocks his/her knees and anteriorly tilts his pelvis, flexing only slightly at the lumbar spine. Poor control will be present when he locks out and hyperextends the knees; he/she should not tilt his pelvis but instead should flex markedly at the lumbar and thoracic spine.

Fig. 11. Forward bending test.

#### **3. Phases of treatment: Lumbopelvic stabilization program**

The first consideration before establishing phases of treatment is to determine testing procedures. Many experimental assessment procedures, some of them described before, give essential information about joint protection mechanisms, especially in the lumbopelvic region.

Lumbopelvic stabilization program needs to involve a problem-solving approach, where clinical tests, reflecting the dysfunction mechanisms, are used to decide the best type of treatment approach for an individual client. In order to achieve this, assessments and their related treatments have been simplified by dividing them into progressive stages, where one stage of assessment and treatment is ideally completed prior to proceeding to the next stage. The segmental approach we have devised develops through three stages of segmental control, with each stage exposing the individual patient to increasing challenges to his/her joint protection mechanisms (Richardson et al., 2004).


#### **3.1 Phase 1**

276 Low Back Pain

Patient stands with his/her feet shoulder-width apart, facing the seat of a chair. He/she is instructed to bend forward, to touch the chair seat, and to stand back up again. Optimal control occurs when the patient unlocks his/her knees and anteriorly tilts his pelvis, flexing only slightly at the lumbar spine. Poor control will be present when he locks out and hyperextends the knees; he/she should not tilt his pelvis but instead should flex markedly

at the lumbar and thoracic spine.

Fig. 11. Forward bending test.

**3. Phases of treatment: Lumbopelvic stabilization program** 

The first consideration before establishing phases of treatment is to determine testing procedures. Many experimental assessment procedures, some of them described before, Key: Segmental control over primary stabilizers.

We refer to re-establishing directly the simultaneous contraction of the deep muscle synergy independently of the secondary stabilizers and mobilizers. This simultaneous contraction of the synergy, independent of the global muscles, should occur with the postural cue to "draw in the abdominal wall". The weight of the body is minimized in order to allow the patient to focus on this specific skill involved in joint protection.

Training local segmental control involves activating and facilitating the local muscle system, while using techniques (e.g. feedback) to reduce the contribution of the global muscles, most particularly the mobilizers. Instructional cues, body position and various feedback techniques (including palpation, electromyography and real-time ultrasound) are used simultaneously to facilitate the local synergy and inhibit or relax the more active global muscles. The ability to hold this pattern through developing specific muscular control, without addition of any load, may serve also to help to restore kinaesthetic awareness and lumbopelvic position sense, usually found to be impaired in the patient with low back pain.

The precise position of the lumbopelvic region may itself be facilitatory for activation of the local synergy muscles. Recent research has shown that better co-activation of the TrA occurs when the pelvic floor is contracted with the lumbar spine place in a more neutral position (Sapsford et al., 1997b). There is a consensus that local muscles are involved in segmental support and, therefore, contribute to the precise positioning of the lumbosacral curve.

#### **Lumbar multifidus activation**

In order to get a suitable activation of lumbar multifidus (LM), a submaximal contraction was elicited with the contralateral arm lift maneuver, while holding a small hand weight, as previously demonstrated to elicit approximately 30% of the maximal voluntary contraction of the LM muscle (Koppenhaver et al., 2011).

Stabilization Exercise for the Management of Low Back Pain 279

Fig. 14. Abdominal hollowing: activation of transversus abdominis in sitting.

Fig. 15. Abdominal hollowing: activation of transversus abdominis in four point kneeling.

Fig. 16. Activation of multifidus from sitting to lumbar neutral position: looking for neutral

position.

Fig. 12. Activation of multifidus in prone position.

Transversus abdominis activation

In order to get a suitable contraction of TrA, we propose to use the hollowing-in maneuver. Performance of the abdominal hollowing maneuver may be difficult, even in healthy subjects. Contraction of the pelvic floor muscles may promote contraction of the TrA during the abdominal hollowing maneuver. Participants were instructed to "take a relaxed breath in and out, hold the breath out and then draw in your lower abdomen without moving your spine." Alternate cues of "cut off the flow of urine" or "close your rear passage" were sometimes given in an attempt to optimize contraction of the TrA with minimal to no thickening of the internal oblique (IO) muscle (Koppenhaver et al., 2011).

Fig. 13. Abdominal hollowing; activation of transversus abdominis in crook-lying position.

In order to get a suitable contraction of TrA, we propose to use the hollowing-in maneuver. Performance of the abdominal hollowing maneuver may be difficult, even in healthy subjects. Contraction of the pelvic floor muscles may promote contraction of the TrA during the abdominal hollowing maneuver. Participants were instructed to "take a relaxed breath in and out, hold the breath out and then draw in your lower abdomen without moving your spine." Alternate cues of "cut off the flow of urine" or "close your rear passage" were sometimes given in an attempt to optimize contraction of the TrA with minimal to no

Fig. 13. Abdominal hollowing; activation of transversus abdominis in crook-lying position.

thickening of the internal oblique (IO) muscle (Koppenhaver et al., 2011).

Fig. 12. Activation of multifidus in prone position.

Transversus abdominis activation

Fig. 14. Abdominal hollowing: activation of transversus abdominis in sitting.

Fig. 15. Abdominal hollowing: activation of transversus abdominis in four point kneeling.

Fig. 16. Activation of multifidus from sitting to lumbar neutral position: looking for neutral position.

Stabilization Exercise for the Management of Low Back Pain 281

Fig. 18. Closed chain lunge exercises, with the addition of hand weights.

Fig. 19. Bridge in prone position

#### **3.2 Phase 2**

Key: Exercises in closed chain, low velocity and low load.

The purpose is to maintain local muscle synergy contraction, while gradually progressing load cues through the body using weightbearing closed chain exercises. Weightbearing load is added very slowly, ensuring any weightbearing muscle at any kinetic chain segment is activated in order to give effective antigravity support and provide efficient and safe load transfer through the segments of the body. The focus is especially to ensure activation of the local and weightbearing muscles of the lumbar spine and pelvis, and the ability to maintain a static lumbolpelvic posture for weightbearing. These muscles are likely to be dysfunctional in patients with low back pain. In addition, lifestyle factors of many individuals, which could have led to a dysfunction in these muscles, need to be addressed, as they may place them at risk of sustaining further low back injury.

Fig. 17. Stand-up position on unstable surface.

The purpose is to maintain local muscle synergy contraction, while gradually progressing load cues through the body using weightbearing closed chain exercises. Weightbearing load is added very slowly, ensuring any weightbearing muscle at any kinetic chain segment is activated in order to give effective antigravity support and provide efficient and safe load transfer through the segments of the body. The focus is especially to ensure activation of the local and weightbearing muscles of the lumbar spine and pelvis, and the ability to maintain a static lumbolpelvic posture for weightbearing. These muscles are likely to be dysfunctional in patients with low back pain. In addition, lifestyle factors of many individuals, which could have led to a dysfunction in these muscles, need to be addressed, as they may place

Key: Exercises in closed chain, low velocity and low load.

them at risk of sustaining further low back injury.

Fig. 17. Stand-up position on unstable surface.

**3.2 Phase 2** 

Fig. 18. Closed chain lunge exercises, with the addition of hand weights.

Fig. 19. Bridge in prone position

Stabilization Exercise for the Management of Low Back Pain 283

Fig. 22. Lower limb abduction.

Fig. 23. Knee extension in supine position on roller.

Fig. 20. Bridge in supine position.

Fig. 21. Lateral bridge.

#### **3.3 Phase 3**

Key: Exercises in open chain, high velocity and high load.

The aim is to continue to maintain local segmental control while load is added through open kinetic chain movement of adjacent segments. This final step is to direct progression so that all muscles are integrated into functional movement tasks in a formal way.

This third stage allows any loss of local segmental control during high loaded open chain tasks to be detected, as well as ensuring that there is no compensation by the more active (i.e. non-weightbearing) muscles. In addition, loss of range of asymmetry of joints adjacent to the lumbopelvic region needs to be addressed to ensure that loss of movement range does not interfere with the ability of the individual to maintain lumbopelvic stability during movement.

Fig. 22. Lower limb abduction.

282 Low Back Pain

Fig. 20. Bridge in supine position.

Fig. 21. Lateral bridge.

Key: Exercises in open chain, high velocity and high load.

The aim is to continue to maintain local segmental control while load is added through open kinetic chain movement of adjacent segments. This final step is to direct progression so that

This third stage allows any loss of local segmental control during high loaded open chain tasks to be detected, as well as ensuring that there is no compensation by the more active (i.e. non-weightbearing) muscles. In addition, loss of range of asymmetry of joints adjacent to the lumbopelvic region needs to be addressed to ensure that loss of movement range does not interfere with the ability of the individual to maintain lumbopelvic stability during

all muscles are integrated into functional movement tasks in a formal way.

**3.3 Phase 3** 

movement.

Fig. 23. Knee extension in supine position on roller.

Stabilization Exercise for the Management of Low Back Pain 285

Return to the neutral position when the exercise is complete and keep their abdomens

 Progression with stability ball exercises: we might start with 8 to 10 repetitions, and then increase to 12 to 15. At first a slow count of 4 to 5 to move into a holding position should be used; hold the designated position for a count of 5, and then use a count of 4 or 5 to move back into the starting position. Patients can progress by adding reps or

Sitting knee raise on gym ball. Goal: maintain stability in the presence of hip movement

**4.1.1 Practical considerations (Norris, 2008)**  Patients should warm up before use them.

increasing the holding time.

on a reduced base of support.

Fig. 25. Sitting knee raise on gym ball.

**4.1.2 Some exercises** 

hollowed when stress is imposed on the spine.

Deflate the ball slightly to increase its contact area.

Begin with simple actions and progress to more complex movements.

Fig. 24. Open chain exercise of upper limb after co-contraction of transversus abdominis and multifidus.

#### **4. Gym ball and foam roller exercises**

#### **4.1 Gym ball**

We can obtain good levels of stability using exercise with gym balls (also called stability balls or Swiss balls). These exercises require quite complex movements and will help increase the stability already obtained through previous exercises in this book. They can also strengthen stability muscles that otherwise might not be exercised. It is an inexpensive and effective apparatus for back stability. A 26 in. (65 cm) gym ball provides the optimal sitting position for most people although it can be used 21.6 in. (55) cm and 29.5 in. (75 cm). People should be able to sit on the ball with their femurs horizontal and their hips and knees both at 90º to 100º of flexion, so that their knees are slightly below their hips.

#### **4.1.1 Practical considerations (Norris, 2008)**


#### **4.1.2 Some exercises**

284 Low Back Pain

Fig. 24. Open chain exercise of upper limb after co-contraction of transversus abdominis and

We can obtain good levels of stability using exercise with gym balls (also called stability balls or Swiss balls). These exercises require quite complex movements and will help increase the stability already obtained through previous exercises in this book. They can also strengthen stability muscles that otherwise might not be exercised. It is an inexpensive and effective apparatus for back stability. A 26 in. (65 cm) gym ball provides the optimal sitting position for most people although it can be used 21.6 in. (55) cm and 29.5 in. (75 cm). People should be able to sit on the ball with their femurs horizontal and their hips and knees both

at 90º to 100º of flexion, so that their knees are slightly below their hips.

multifidus.

**4.1 Gym ball** 

**4. Gym ball and foam roller exercises** 

 Sitting knee raise on gym ball. Goal: maintain stability in the presence of hip movement on a reduced base of support.

Fig. 25. Sitting knee raise on gym ball.

Stabilization Exercise for the Management of Low Back Pain 287

 Bridge with therapist pressure. Goal: strengthen hip and trunk stability muscles by challenging stability with continuously variable overload from multiple directions.

Basic superman. Goal: strengthen the spinal and hip extensors.

Fig. 28. Basic superman.

Fig. 29. Bridge with therapist pressure.

Abdominal slide. Goal: control action of the rectus abdominis while moving.

Fig. 26. Abdominal slide.

Lying trunk curl with leg lift. Goal: strengthen upper and lower abdominals.

Fig. 27. Lying trunk curl with leg lift.

Basic superman. Goal: strengthen the spinal and hip extensors.

Fig. 28. Basic superman.

286 Low Back Pain

Abdominal slide. Goal: control action of the rectus abdominis while moving.

Lying trunk curl with leg lift. Goal: strengthen upper and lower abdominals.

Fig. 26. Abdominal slide.

Fig. 27. Lying trunk curl with leg lift.

 Bridge with therapist pressure. Goal: strengthen hip and trunk stability muscles by challenging stability with continuously variable overload from multiple directions.

Fig. 29. Bridge with therapist pressure.

Stabilization Exercise for the Management of Low Back Pain 289

Prone tuck on roller. Goal: to develop whole trunk strength and range of motion.

Lumbopelvic stabilization approach seems to be useful for the management of low back pain. Based on a solid biomechanical model (Panjabi's hypotheses), it has demonstrated positive effects over pain and return to activity, but it is not clear the optimal type of exercise, duration or number of repetitions, among other variables. Furthermore there is no strong evidence that conclude whether lumbopelvic stabilization programs provide better

Fig. 31. Bridge with heel raise on roller.

Fig. 32. Prone tuck on roller.

**5. Conclusions** 

#### **4.2 Foam roller**

Foam rollers are commonly used within physical therapy for rehabilitation and during exercise classes such as Pilates (Norris, 2008). They are normally 3 ft (1 m) long and either 3 or 6 in. (7.6 or 15.2 cm) in diameter. Rollers may be either full rolls (circles) or half rolls (Dshaped), made of polyurethane or similar materials, which are durable and suitable for weight bearing up to 350 lb (150kg) (figures 23, 30, 31 and 32).

Because the rollers are narrow, their contact area with the floor is quite small, making them ideal as an unstable base of support. Because they are firm but forgiving, they are especially useful for exercises that require direct body contact. Foam rollers have the advantage over wooden wooble boards in this feature.

Each exercise should be performed for 10 repetitions or 5 reps to each side (10 in total) if using single-side movements. Because these are balance exercises, they may be progressed through timing and complexity.

#### **4.2.1 Some exercises**

Supine-lying leg lift. Goal: to develop back stability in an unstable lying position.

Fig. 30. Supine-lying leg lift.

 Bridge with heel raise on roller. Goal: develop spinal extensor and gluteal muscle endurance on an unstable platform.

Foam rollers are commonly used within physical therapy for rehabilitation and during exercise classes such as Pilates (Norris, 2008). They are normally 3 ft (1 m) long and either 3 or 6 in. (7.6 or 15.2 cm) in diameter. Rollers may be either full rolls (circles) or half rolls (Dshaped), made of polyurethane or similar materials, which are durable and suitable for

Because the rollers are narrow, their contact area with the floor is quite small, making them ideal as an unstable base of support. Because they are firm but forgiving, they are especially useful for exercises that require direct body contact. Foam rollers have the advantage over

Each exercise should be performed for 10 repetitions or 5 reps to each side (10 in total) if using single-side movements. Because these are balance exercises, they may be progressed

Bridge with heel raise on roller. Goal: develop spinal extensor and gluteal muscle

Supine-lying leg lift. Goal: to develop back stability in an unstable lying position.

weight bearing up to 350 lb (150kg) (figures 23, 30, 31 and 32).

wooden wooble boards in this feature.

through timing and complexity.

**4.2.1 Some exercises** 

Fig. 30. Supine-lying leg lift.

endurance on an unstable platform.

**4.2 Foam roller** 

Fig. 31. Bridge with heel raise on roller.

Prone tuck on roller. Goal: to develop whole trunk strength and range of motion.

#### **5. Conclusions**

Lumbopelvic stabilization approach seems to be useful for the management of low back pain. Based on a solid biomechanical model (Panjabi's hypotheses), it has demonstrated positive effects over pain and return to activity, but it is not clear the optimal type of exercise, duration or number of repetitions, among other variables. Furthermore there is no strong evidence that conclude whether lumbopelvic stabilization programs provide better

Stabilization Exercise for the Management of Low Back Pain 291

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**6. References** 


**13** 

*USA* 

Kyndall Boyle

*Appalachian State University* 

**Conservative Management for Patients** 

Conditions involving one or both sacroiliac joints (SIJs) are often referred to as sacroiliac joint pain (SIJP), sacroiliac joint dysfunction (SIJD), or pelvic girdle pain (PGP). SIJP is defined as pain arising from intra-articular structures such as the anterior sacroiliac ligament, posterior sacroiliac ligament, interosseous ligaments, and articular cartilage in the SIJ. SIJD is a state of altered mechanics, either an increase or decrease from the expected normal or the presence of an aberrant motion.1 It includes pain arising from extra-articular structures that surround the SIJs such as the sacrotuberous, sacrospinous, and/or iliolumbar ligaments. Lastly, PGP is pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the SIJs.2 SIJP and SIJD are therefore considered

The prevalence of sacroiliac joint pain has been reported between 13-30%.3, 4 Specifically 13% of individuals with low back pain have pain arising from the SIJ as evidenced by relief of their pain after an intra-articular anesthetic block.3 Thirty percent of all patients seen in outpatient clinics have pain arising from the SIJs,4 25% of pregnant women have PGP, and 7%

Making a clinical diagnosis of a patient with certainty that pain is originating from the SIJs is challenging.1 Reliability and validity of many special tests (particularly motion palpation tests) are poor6, 7, and the existence of a Gold standard test is controversial.4, 8 Subjective history specifics, location of pain/symptoms, and special tests called provocation testing are helpful and important in this endeavor. Patients who complain of pain when they arise after long term sitting present a classic sign of pain from the SIJs.9 It is also common for patients to point directly over their left (L) and/or right (R) SIJs (posterior superior iliac spine (PSIS) region). This is referred to as Fortin's Finger Test.10 A complaint of *unilateral* pain (on one side only) rather than bilateral pain is also considered more likely to be coming from an SIJ.9 Another classic sign indicative of SIJ pain referral is the absence of lumbar pain above L5.9 Pain perceived over one or both PSIS/SIJs and just lateral and/or inferior, in the buttock, is also a strong indicator of SIJP.11 This area is called Fortin's Area and was discovered and

**1. Introduction** 

subgroups of PGP. 2

**2. Diagnosis** 

**2.1 Subjective data** 

of post partum women have "serious" PGP.5

**with Sacroiliac Joint Dysfunction** 


### **Conservative Management for Patients with Sacroiliac Joint Dysfunction**

Kyndall Boyle *Appalachian State University USA* 

### **1. Introduction**

292 Low Back Pain

Panjabi MM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol 2003; 13:

Pereira LM, Obara K, Dias JM, Menacho MO, Guariglia DA, Schiavoni D, Pereira HM,

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Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for

White AA, Panjabi MM. Clinical biomechanics of the spine. Philadelphia: JB Lippincott;

White SG, Sahrmann SA. A movement system balance approach to management of

Zazulak B, Cholewicki J, Reeves NP. Neuromuscular control of trunk stability: clinical

Cardoso JR. Comparing the Pilates method with no exercise or lumbar stabilization for pain and functionality in patients with chronic low back pain: Systematic

their ability to provide stabilization for the lumbar spine. Aust J Physiother 1990;

Motor Control Approach for the Treatment and Prevention of Low Back Pain. 2 ed.

musculoskeletal pain. In: Grant R. Physical therapy of the cervical and thoracic

implications for sports injury prevention. J Am Acad Orthop Surg 2008; 16(9): 497-

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acute low back pain. Br J General Pract 1997; 47: 647-52.

371–9.

36: 6-11.

1978.

505.

Conditions involving one or both sacroiliac joints (SIJs) are often referred to as sacroiliac joint pain (SIJP), sacroiliac joint dysfunction (SIJD), or pelvic girdle pain (PGP). SIJP is defined as pain arising from intra-articular structures such as the anterior sacroiliac ligament, posterior sacroiliac ligament, interosseous ligaments, and articular cartilage in the SIJ. SIJD is a state of altered mechanics, either an increase or decrease from the expected normal or the presence of an aberrant motion.1 It includes pain arising from extra-articular structures that surround the SIJs such as the sacrotuberous, sacrospinous, and/or iliolumbar ligaments. Lastly, PGP is pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the SIJs.2 SIJP and SIJD are therefore considered subgroups of PGP. 2

The prevalence of sacroiliac joint pain has been reported between 13-30%.3, 4 Specifically 13% of individuals with low back pain have pain arising from the SIJ as evidenced by relief of their pain after an intra-articular anesthetic block.3 Thirty percent of all patients seen in outpatient clinics have pain arising from the SIJs,4 25% of pregnant women have PGP, and 7% of post partum women have "serious" PGP.5

### **2. Diagnosis**

#### **2.1 Subjective data**

Making a clinical diagnosis of a patient with certainty that pain is originating from the SIJs is challenging.1 Reliability and validity of many special tests (particularly motion palpation tests) are poor6, 7, and the existence of a Gold standard test is controversial.4, 8 Subjective history specifics, location of pain/symptoms, and special tests called provocation testing are helpful and important in this endeavor. Patients who complain of pain when they arise after long term sitting present a classic sign of pain from the SIJs.9 It is also common for patients to point directly over their left (L) and/or right (R) SIJs (posterior superior iliac spine (PSIS) region). This is referred to as Fortin's Finger Test.10 A complaint of *unilateral* pain (on one side only) rather than bilateral pain is also considered more likely to be coming from an SIJ.9 Another classic sign indicative of SIJ pain referral is the absence of lumbar pain above L5.9 Pain perceived over one or both PSIS/SIJs and just lateral and/or inferior, in the buttock, is also a strong indicator of SIJP.11 This area is called Fortin's Area and was discovered and

Conservative Management for Patients with Sacroiliac Joint Dysfunction 295

erector spinae. The abdomen may also bulge, potentially indicating that the patient is holding their breath during the test to compensate for poor load transfer.13 The clinician then repeats the test while applying manual pelvic compression in the area of compensatory motion (Figure 2). The clinician asks the patient if the heaviness or effort of lifting their leg has decreased. The test is positive if effort or heaviness is lessened or abolished with manual compression. A positive test indicates the need for greater stability around the SIJ, also

Pain provocation tests (PPTs) such as Resisted Abduction, Patrick's Sign, Distraction, Gaenslen's, and Sacral Thrust have shown adequate reliability, sensitivity, and specificity, especially when performed as a cluster.8 14, 15 PPTs are limited by the difficulty they present for the clinician to identify whether intra-articular or peri-articular structures are stressed by the tests. The possibility of false negatives due to physical properties of the tissues constitutes another limitation and may require PPTs to be held up to two minutes to avoid.16 From my observation over 21 years, they are seldomly held for that length of time in the clinic. Three or more positive PPTs appear to provide the highest discriminatory power, with a sensitivity of .85 and a specificity of .76.8 A few individual PPTs are recommended: The Thigh Thrust Test, also called the Posterior Shear Test, and the Compression Test.8 The Thigh Thrust/Posterior Shear Test has a reported sensitivity of .81 and specificity of .66 (Figure 3). The Compression Test has a reported sensitivity of .63 and specificity of .69

Fig. 2. Active Straight leg Raise (ASLR) with manual compression

called force closure, which will be discussed later in this chapter.

Copyright © Kyndy Boyle 2010, used with permission

**3.2 Pain provocation tests** 

(Figure 4).

defined as three centimeters lateral to the PSIS/SIJ and ten centimeters caudal to the PSIS/SIJ, based on a study in which the SIJs were injected with a contrast medium (arthrography) to stimulate pain, and then the area of referred pain was mapped.11

#### **3. Special tests**

#### **3.1 Load transfer**

A myriad of special tests have been discussed in the literature, including a load transfer test12, many provocation tests designed to provoke pain in one or both SIJs, and motion palpation tests designed to assess asymmetry in SIJ motion and/or hyper- or hypomobility of the SIJs. The Active Straight Leg Raise Test (ASLR) assesses the ability of the patient to effectively transfer load between their lower limbs and trunk.12 This test can be used to help rule in pain arising from the SIJ(s) but is not limited to the SIJs. The ASLR test can also be used to assess many conditions involving the trunk and pelvis. The test is done with the patient lying supine. The clinician then asks the patient to raise their leg 5 cm off the supporting surface (plinth) (Figure 1) and determines how much effort was required on a scale of 0-5 (0=No effort, 5=Max effort).13 If the patient has optimal ability to effectively transfer load during the test, the leg will rise up effortlessly without any pelvic movement. The clinician observes for movement during the test and watches for compensatory movement resulting from instability. Examples of aberrant motion may include drawing the rib cage inward from over activation of the external obliques, flaring the lower ribs out from over activation of the internal obliques or thoracic extension from over activation of the

Fig. 1. Active Straight Leg Raise (ASLR) (step one) Copyright © Kyndy Boyle 2010, used with permission

defined as three centimeters lateral to the PSIS/SIJ and ten centimeters caudal to the PSIS/SIJ, based on a study in which the SIJs were injected with a contrast medium

A myriad of special tests have been discussed in the literature, including a load transfer test12, many provocation tests designed to provoke pain in one or both SIJs, and motion palpation tests designed to assess asymmetry in SIJ motion and/or hyper- or hypomobility of the SIJs. The Active Straight Leg Raise Test (ASLR) assesses the ability of the patient to effectively transfer load between their lower limbs and trunk.12 This test can be used to help rule in pain arising from the SIJ(s) but is not limited to the SIJs. The ASLR test can also be used to assess many conditions involving the trunk and pelvis. The test is done with the patient lying supine. The clinician then asks the patient to raise their leg 5 cm off the supporting surface (plinth) (Figure 1) and determines how much effort was required on a scale of 0-5 (0=No effort, 5=Max effort).13 If the patient has optimal ability to effectively transfer load during the test, the leg will rise up effortlessly without any pelvic movement. The clinician observes for movement during the test and watches for compensatory movement resulting from instability. Examples of aberrant motion may include drawing the rib cage inward from over activation of the external obliques, flaring the lower ribs out from over activation of the internal obliques or thoracic extension from over activation of the

(arthrography) to stimulate pain, and then the area of referred pain was mapped.11

**3. Special tests 3.1 Load transfer** 

Fig. 1. Active Straight Leg Raise (ASLR) (step one) Copyright © Kyndy Boyle 2010, used with permission

Fig. 2. Active Straight leg Raise (ASLR) with manual compression Copyright © Kyndy Boyle 2010, used with permission

erector spinae. The abdomen may also bulge, potentially indicating that the patient is holding their breath during the test to compensate for poor load transfer.13 The clinician then repeats the test while applying manual pelvic compression in the area of compensatory motion (Figure 2). The clinician asks the patient if the heaviness or effort of lifting their leg has decreased. The test is positive if effort or heaviness is lessened or abolished with manual compression. A positive test indicates the need for greater stability around the SIJ, also called force closure, which will be discussed later in this chapter.

#### **3.2 Pain provocation tests**

Pain provocation tests (PPTs) such as Resisted Abduction, Patrick's Sign, Distraction, Gaenslen's, and Sacral Thrust have shown adequate reliability, sensitivity, and specificity, especially when performed as a cluster.8 14, 15 PPTs are limited by the difficulty they present for the clinician to identify whether intra-articular or peri-articular structures are stressed by the tests. The possibility of false negatives due to physical properties of the tissues constitutes another limitation and may require PPTs to be held up to two minutes to avoid.16 From my observation over 21 years, they are seldomly held for that length of time in the clinic. Three or more positive PPTs appear to provide the highest discriminatory power, with a sensitivity of .85 and a specificity of .76.8 A few individual PPTs are recommended: The Thigh Thrust Test, also called the Posterior Shear Test, and the Compression Test.8 The Thigh Thrust/Posterior Shear Test has a reported sensitivity of .81 and specificity of .66 (Figure 3). The Compression Test has a reported sensitivity of .63 and specificity of .69 (Figure 4).

Conservative Management for Patients with Sacroiliac Joint Dysfunction 297

Motion palpation tests such as the Standing Flexion Test, Prone Knee Flexion Test, Supine Long Sitting Test, Sitting PSIS, and Heel-bank Test are not recommended for diagnosing patients with SIJP or SIJD.6, 7, 17 Movement of the SIJ(s) cannot be reliably assessed by manual palpation, especially in weight bearing. The reliability, reported as Kappas between

Two opinions exist as to whether there is a gold standard for diagnosis of SIJP/SIJD. One opinion claims that anesthetic block procedures are the gold standard. 18 This would require a physician to inject one or both SIJs with an anesthetic to determine if the patient's pain is abolished or lessened as a result of the injection. The other opinion claims that there is no gold standard.19 Anesthetic block procedures are considered effective if the patient's pain originates from intra-articular structures but not effective if their pain arises from extraarticular structures, such as accessory ligaments and muscle tissue that surrounds the joint.19

The sacroiliac joints involve the right and left ilium and their C-shaped articulations with the lateral sides of the sacrum.20 Each iliac surface is lined with fibrocartilage and each sacral surface is lined with articular/hyaline cartilage.20 Optimal SIJ function depends on optimal positioning and movement of six joints: both SIJ, the L5-S1 articulation, the pubic symphysis, and both hip joints (left and right acetabula and femoral heads). The SIJs are inherently stable and their design gives them the ability to safely transfer very high compressive loads under normal conditions.20 Although it was once believed that no movement occurred at the SIJs, several research studies have since demonstrated that this is not the case.21, 22 Patients undergoing a lumbar fusion, will likely have a resulting increase in SIJ motion and stress, as these joints are just distal to the fused segments. 23 Unilateral SIJ fusion has been documented to cause undesirable strain and load requirements on the contralateral SIJ.22 The amount of motion that may occur at the SIJs depends on whether or not the joints are loaded, and on the position of the hip joints in their range of motion (ROM). Research study results have also depended on whether fresh cadavers were used.22 SIJs that are loaded or in weight bearing are thought to move less than in non-weight bearing.21 SIJ motion appears to be greater when the hip joints are at their end range, versus

According to research, the SIJs may function as hip joints to get needed motion for gait and other movements which results in SIJ ligament strain.24 The innominate bone will generally displace in the same direction as the hip, and act as an extension of the femur when the hip is at its end ROM and the innominate through the SIJ will attempt to gain more hip motion.24 A fresh cadaver study conducted within 24 hours of death of five donors reported sagittal plane motion of the SIJ between three to 17 degrees, and translation range was reported between four to eight millimeters (mm). 22 Authors of another study that did not use fresh cadavers reported SIJ rotation in a non-weight bearing position to be 2.5 degrees

and 0.2 degrees in a weight bearing position.21 Translation was reported as 1.6mm.21

A study using kinematic data with a magnetic tracking device reported that the right SIJ is capable of greater ROM than the L SIJ.24 This study was done on 40 subjects including both

**3.3 Motion palpation tests** 

0.19-0.37, is too low for clinical use.

**3.4 Biomechanics/anatomy** 

a neutral position.

Fig. 3. Posterior Shear Test (Pain Provocation) Copyright © Kyndy Boyle 2010, used with permission

Fig. 4. Compression Test (Pain Provocation) Copyright © Kyndy Boyle 2010, used with permission

#### **3.3 Motion palpation tests**

296 Low Back Pain

Fig. 3. Posterior Shear Test (Pain Provocation)

Fig. 4. Compression Test (Pain Provocation)

Copyright © Kyndy Boyle 2010, used with permission

Copyright © Kyndy Boyle 2010, used with permission

Motion palpation tests such as the Standing Flexion Test, Prone Knee Flexion Test, Supine Long Sitting Test, Sitting PSIS, and Heel-bank Test are not recommended for diagnosing patients with SIJP or SIJD.6, 7, 17 Movement of the SIJ(s) cannot be reliably assessed by manual palpation, especially in weight bearing. The reliability, reported as Kappas between 0.19-0.37, is too low for clinical use.

Two opinions exist as to whether there is a gold standard for diagnosis of SIJP/SIJD. One opinion claims that anesthetic block procedures are the gold standard. 18 This would require a physician to inject one or both SIJs with an anesthetic to determine if the patient's pain is abolished or lessened as a result of the injection. The other opinion claims that there is no gold standard.19 Anesthetic block procedures are considered effective if the patient's pain originates from intra-articular structures but not effective if their pain arises from extraarticular structures, such as accessory ligaments and muscle tissue that surrounds the joint.19

#### **3.4 Biomechanics/anatomy**

The sacroiliac joints involve the right and left ilium and their C-shaped articulations with the lateral sides of the sacrum.20 Each iliac surface is lined with fibrocartilage and each sacral surface is lined with articular/hyaline cartilage.20 Optimal SIJ function depends on optimal positioning and movement of six joints: both SIJ, the L5-S1 articulation, the pubic symphysis, and both hip joints (left and right acetabula and femoral heads). The SIJs are inherently stable and their design gives them the ability to safely transfer very high compressive loads under normal conditions.20 Although it was once believed that no movement occurred at the SIJs, several research studies have since demonstrated that this is not the case.21, 22 Patients undergoing a lumbar fusion, will likely have a resulting increase in SIJ motion and stress, as these joints are just distal to the fused segments. 23 Unilateral SIJ fusion has been documented to cause undesirable strain and load requirements on the contralateral SIJ.22 The amount of motion that may occur at the SIJs depends on whether or not the joints are loaded, and on the position of the hip joints in their range of motion (ROM). Research study results have also depended on whether fresh cadavers were used.22 SIJs that are loaded or in weight bearing are thought to move less than in non-weight bearing.21 SIJ motion appears to be greater when the hip joints are at their end range, versus a neutral position.

According to research, the SIJs may function as hip joints to get needed motion for gait and other movements which results in SIJ ligament strain.24 The innominate bone will generally displace in the same direction as the hip, and act as an extension of the femur when the hip is at its end ROM and the innominate through the SIJ will attempt to gain more hip motion.24 A fresh cadaver study conducted within 24 hours of death of five donors reported sagittal plane motion of the SIJ between three to 17 degrees, and translation range was reported between four to eight millimeters (mm). 22 Authors of another study that did not use fresh cadavers reported SIJ rotation in a non-weight bearing position to be 2.5 degrees and 0.2 degrees in a weight bearing position.21 Translation was reported as 1.6mm.21

A study using kinematic data with a magnetic tracking device reported that the right SIJ is capable of greater ROM than the L SIJ.24 This study was done on 40 subjects including both

Conservative Management for Patients with Sacroiliac Joint Dysfunction 299

The GM provides stability to the lumbopelvic region13 and to the hip joints 32 and the deep fibers of the GM cross the SIJs. 33 The architecture of the piriformis lends itself to an angle of pull roughly transverse to the joint via its proximal attachment to the inferior lateral sacrum and the superior greater trochanter of the femur.34 Even though the coccygeus is inferior to the SIJs, its line of pull from the proximal attachment site at the ischial spine to the distal

The R and L respiratory hemi-diaphragms do not cross the SIJs however they are considered inner-core muscles. 13 If one hemidiaphragm pulls on the distal attachment site on the lumbar vertebrae more than the other, the entire sacrum could orient itself in contralateral rotation. The diaphragm and its position and contraction along with abdominal muscles influence the degree of intra-abdominal pressure (IAP) which can also aid in stability across the SIJs. Research by Hodges has elucidated the role of the diaphragm in increasing IAP prior to limb movement that occurs simultaneously with TA activation.35 The respiratory diaphragm's contraction occurs before limb movement to aid in trunk stability. When demands are placed on the trunk such as the anticipation of fast upper extremity movement, the respiratory diaphragm is used more for stability of the trunk and for postural control than it is used for respiration. The diaphragm's primary role is for respiration and its role as a postural muscle or lumbar stabilizer is secondary.35 When the diaphragm contracts too much, it can become more linear and loose its position and shape for the area of the diaphragm known as the zone of apposition (ZOA). The ZOA is the area of the diaphragm that encompasses the cylindrical portion of the diaphragm which corresponds to the portion directly apposed (adjacent) to the inner aspect of the lower rib cage.36 37, 38 During exhalation, the ZOA should account for approximately 30% of the surface area of the diaphragm.36 Importance of the ZOA is multifactoral. The ZOA is important because when the ZOA is decreased compared to optimal there is less descent of the dome of the diaphragm and less appositional diaphragm forces.39 The diaphragm is therefore less effective during its inspiratory muscle action and has less ability to expand the lower rib cage.40 Decreased ZOA will result in less IAP and may result in a short diaphragm.41 Exercise tolerance has been reported to decrease with suboptimal (decreased) ZOA.42

There is a polyarticular chain of muscles where the diaphragm overlaps with the psoas muscle at the distal attachment of the diaphragm and the proximal attachment of the psoas.34 The diaphragm can pull the lumbar spine up/cephalad/superior and forward/anterior and the psoas can pull the spine down/caudal/inferior and forward/anterior. (Figure 5) This situation would result in a decrease in IAP, an increase in lordosis and anterior pelvic tilt and lengthening of the abdominals.41 This excessive pull on the diaphragm occurs with splinting or

There is a relationship between suboptimal or faulty respiration, motor control strategies, posture and SIJP.28 O'Sullivan et al. investigated the relationships between breathing and motor control strategies for patients with SIJP during an Active Straight Leg Raise (ASLR) test using real time ultrasound and spirometry. They reported that the subjects with SIJP have suboptimal breathing as evidenced by an increase in their respiration rate compared to controls. They also reported that subjects with SIJP had suboptimal core muscle function as evidenced by depression of the pelvic floor rather than optimal and expected pelvic floor elevation which was seen in the controls. Additionally diaphragm excursion was decreased compared to the controls. The authors noted that the subjects with SIJP had altered motor

breath holding of the diaphragm and during situations of hyperinflation.43, 44

attachment of the coccyx and anococcygeal ligament is transverse to the SIJs.34

females and males from 18-35 years who were pain free in their SIJs/low back and had no history of injury.24 Sagittal plane motion was reported as 60% greater on the R than the L in a cadaver study using Computerized Tomography (CT) on subjects from 52-68 years. The average motion on the right was eight degrees and five degrees on the left.22 No explanation for the increase in R sided motion was given.

It was once believed that an increase in bilateral laxity of the SIJs as a result of pregnancy from the release of the hormone relaxin was associated with SIJP. This belief however was disputed by a study by Damen who reported that increased motion/laxity of the SIJS is not related to pain for pregnant women.25 He reported however that increased laxity of just *one* SIJ was related to pain. Pregnant women with "moderate to severe" SIJP/PGP had more laxity in one SIJ compared to the other SIJ based on Doppler imaging of vibrations in threshold units. The study was completed on 163 subjects.

Concepts referred to as form and force closure can aid in the stability of the SIJs.13, 26 Form closure is stability achieved by virtue of the shape, structure and orientation of the bones that make up the joints. The R and L iliums interlock on either side, with the sacrum bone nestled in between. This osteological design contributes to the inherent stability of the joints. For optimal form closure however, there needs to be optimal position of each ilium on each side of the sacrum and/or each side of the sacrum on each ilium. Based on my 21 years of practice as a licensed physical therapist, some patients will complain that they feel their SIJ slipping, moving, rubbing or going out of place, usually on the right. These subjective reports may indicate that optimal form closure has been lost, at least temporarily.

Interventions to address positional faults of the SIJ include specific muscle activation using therapeutic exercises, muscle energy techniques and joint manipulation techniques. Joint manipulation techniques may improve pain and function however they do not change the position of the sacrum in relation to the ilium based on Roentgen Stereophotogrammetric Analysis (RSA).27 The benefits of these interventions will be discussed in more detail toward the end of this chapter.

Force closure is the concept of compressive forces that are exerted across the joints to aid in stability.13 SIJP has been associated with both insufficient force closure and *excessive* force closure coming from motor activation of lumbopelvic and surrounding musculature such as the pelvic floor.28 Forces that are perpendicular to the joint surface have the most optimal angle of force to contribute to joint stability. These forces are often generated intrinsically by contracting muscle and can also be generated extrinsically by external supports such as a sacroiliac joint belt. There are several different muscles that act to compress and control the SIJs to enhance their stability and stiffness which allows for effective load transfer via the pelvis during a variety of functional tasks. Muscles that have been described as contributing to force closure include the gluteus maximus (GM), piriformis, and coccygeus of the pelvic floor, respiratory diaphragm, transverse abdominus (TA) and the internal oblique (IO). 12, 29 <sup>30</sup> 31 Those muscles that are transversely oriented such as the TA, IO, piriformis and coccygeus are positioned the best to contribute to increased SIJ ligament stiffness. When laxity of ligaments associated with the SIJs decrease and the stiffness increases, then force closure of the SIJs will increase. Richardson reported that independent contraction of the TA affects SIJ laxity/stiffness more than contraction (bracing) of all the abdominal muscles at once.30

females and males from 18-35 years who were pain free in their SIJs/low back and had no history of injury.24 Sagittal plane motion was reported as 60% greater on the R than the L in a cadaver study using Computerized Tomography (CT) on subjects from 52-68 years. The average motion on the right was eight degrees and five degrees on the left.22 No explanation

It was once believed that an increase in bilateral laxity of the SIJs as a result of pregnancy from the release of the hormone relaxin was associated with SIJP. This belief however was disputed by a study by Damen who reported that increased motion/laxity of the SIJS is not related to pain for pregnant women.25 He reported however that increased laxity of just *one* SIJ was related to pain. Pregnant women with "moderate to severe" SIJP/PGP had more laxity in one SIJ compared to the other SIJ based on Doppler imaging of vibrations in

Concepts referred to as form and force closure can aid in the stability of the SIJs.13, 26 Form closure is stability achieved by virtue of the shape, structure and orientation of the bones that make up the joints. The R and L iliums interlock on either side, with the sacrum bone nestled in between. This osteological design contributes to the inherent stability of the joints. For optimal form closure however, there needs to be optimal position of each ilium on each side of the sacrum and/or each side of the sacrum on each ilium. Based on my 21 years of practice as a licensed physical therapist, some patients will complain that they feel their SIJ slipping, moving, rubbing or going out of place, usually on the right. These subjective

Interventions to address positional faults of the SIJ include specific muscle activation using therapeutic exercises, muscle energy techniques and joint manipulation techniques. Joint manipulation techniques may improve pain and function however they do not change the position of the sacrum in relation to the ilium based on Roentgen Stereophotogrammetric Analysis (RSA).27 The benefits of these interventions will be discussed in more detail toward

Force closure is the concept of compressive forces that are exerted across the joints to aid in stability.13 SIJP has been associated with both insufficient force closure and *excessive* force closure coming from motor activation of lumbopelvic and surrounding musculature such as the pelvic floor.28 Forces that are perpendicular to the joint surface have the most optimal angle of force to contribute to joint stability. These forces are often generated intrinsically by contracting muscle and can also be generated extrinsically by external supports such as a sacroiliac joint belt. There are several different muscles that act to compress and control the SIJs to enhance their stability and stiffness which allows for effective load transfer via the pelvis during a variety of functional tasks. Muscles that have been described as contributing to force closure include the gluteus maximus (GM), piriformis, and coccygeus of the pelvic floor, respiratory diaphragm, transverse abdominus (TA) and the internal oblique (IO). 12, 29 <sup>30</sup> 31 Those muscles that are transversely oriented such as the TA, IO, piriformis and coccygeus are positioned the best to contribute to increased SIJ ligament stiffness. When laxity of ligaments associated with the SIJs decrease and the stiffness increases, then force closure of the SIJs will increase. Richardson reported that independent contraction of the TA affects SIJ laxity/stiffness more than contraction (bracing) of all the abdominal muscles at

reports may indicate that optimal form closure has been lost, at least temporarily.

for the increase in R sided motion was given.

the end of this chapter.

once.30

threshold units. The study was completed on 163 subjects.

The GM provides stability to the lumbopelvic region13 and to the hip joints 32 and the deep fibers of the GM cross the SIJs. 33 The architecture of the piriformis lends itself to an angle of pull roughly transverse to the joint via its proximal attachment to the inferior lateral sacrum and the superior greater trochanter of the femur.34 Even though the coccygeus is inferior to the SIJs, its line of pull from the proximal attachment site at the ischial spine to the distal attachment of the coccyx and anococcygeal ligament is transverse to the SIJs.34

The R and L respiratory hemi-diaphragms do not cross the SIJs however they are considered inner-core muscles. 13 If one hemidiaphragm pulls on the distal attachment site on the lumbar vertebrae more than the other, the entire sacrum could orient itself in contralateral rotation. The diaphragm and its position and contraction along with abdominal muscles influence the degree of intra-abdominal pressure (IAP) which can also aid in stability across the SIJs. Research by Hodges has elucidated the role of the diaphragm in increasing IAP prior to limb movement that occurs simultaneously with TA activation.35 The respiratory diaphragm's contraction occurs before limb movement to aid in trunk stability. When demands are placed on the trunk such as the anticipation of fast upper extremity movement, the respiratory diaphragm is used more for stability of the trunk and for postural control than it is used for respiration. The diaphragm's primary role is for respiration and its role as a postural muscle or lumbar stabilizer is secondary.35 When the diaphragm contracts too much, it can become more linear and loose its position and shape for the area of the diaphragm known as the zone of apposition (ZOA). The ZOA is the area of the diaphragm that encompasses the cylindrical portion of the diaphragm which corresponds to the portion directly apposed (adjacent) to the inner aspect of the lower rib cage.36 37, 38 During exhalation, the ZOA should account for approximately 30% of the surface area of the diaphragm.36 Importance of the ZOA is multifactoral. The ZOA is important because when the ZOA is decreased compared to optimal there is less descent of the dome of the diaphragm and less appositional diaphragm forces.39 The diaphragm is therefore less effective during its inspiratory muscle action and has less ability to expand the lower rib cage.40 Decreased ZOA will result in less IAP and may result in a short diaphragm.41 Exercise tolerance has been reported to decrease with suboptimal (decreased) ZOA.42

There is a polyarticular chain of muscles where the diaphragm overlaps with the psoas muscle at the distal attachment of the diaphragm and the proximal attachment of the psoas.34 The diaphragm can pull the lumbar spine up/cephalad/superior and forward/anterior and the psoas can pull the spine down/caudal/inferior and forward/anterior. (Figure 5) This situation would result in a decrease in IAP, an increase in lordosis and anterior pelvic tilt and lengthening of the abdominals.41 This excessive pull on the diaphragm occurs with splinting or breath holding of the diaphragm and during situations of hyperinflation.43, 44

There is a relationship between suboptimal or faulty respiration, motor control strategies, posture and SIJP.28 O'Sullivan et al. investigated the relationships between breathing and motor control strategies for patients with SIJP during an Active Straight Leg Raise (ASLR) test using real time ultrasound and spirometry. They reported that the subjects with SIJP have suboptimal breathing as evidenced by an increase in their respiration rate compared to controls. They also reported that subjects with SIJP had suboptimal core muscle function as evidenced by depression of the pelvic floor rather than optimal and expected pelvic floor elevation which was seen in the controls. Additionally diaphragm excursion was decreased compared to the controls. The authors noted that the subjects with SIJP had altered motor

Conservative Management for Patients with Sacroiliac Joint Dysfunction 301

responses during the ASLR as they attempted to compensate for their lack of ability to transfer load through their lumbopelvic region secondary to suboptimal form and/or force closure. When the ASLR was repeated with manual compression on the subjects with SIJP, their responses normalized: respiratory rate slowed, pelvic floor did not depress and their diaphragm had more excursion. O'Sullivan et al. described three possibilities for their findings. The first possibility was that subjects with SIJP and suboptimal form closure across one or both SIJs may have been a result of a lesion in their ligamentous system which required their diaphragm to be recruited to generate IAP which led to suboptimal respiration. The second possibility was the suboptimal force closure was a result of pain or a motor control deficit that lead to substitution strategies and splinting of the diaphragm which resulted in suboptimal respiration. The third possibility was reasoned as a possible compromise of *both* form and force closure mechanisms. The recommendations that O'Sullivan et al. make in conclusion of their study is that "intervention to integrate control of deep abdominals with the pelvic floor and diaphragm may be effective for patients with SIJP." The authors however do not give any examples of exercises that patients could do to

A biomechanical theory to explain both R and L sided SIJP was developed by Ron Hruska PT. 45-48 His theory supports the concept of the SIJ functioning as a hip joint and also explains why the right SIJ may move more in the sagittal plane than the L SIJ. Through Hruskas 33 years of full time practice as a physical therapy clinician, he has recognized a common pattern of asymmetry that may contribute to a myriad of musculoskeletal conditions including SIJP/SIJD.45 Other musculoskeletal conditions that the asymmetrical pattern may contribute to include thoracic outlet syndrome,44 low back pain,47, 49 sciatica,46 trochanteric bursitis,50 asthma51, pelvic floor pain and proximal hamstring strain.52 This pattern is called the Left Anterior Interior Chain (L AIC) pattern which gives focus to a polyarticular chain of muscles that is anterior to the spine and interior (deep) in the body, which includes the diaphragm and psoas.45, 53 47 The belief is that this chain of muscles becomes imbalanced because of several factors such as the asymmetrical position of organs, asymmetrical forces exerted by the diaphragm and hemisphere dominance.45 The pattern is thought to manifest in both right handed and L handed individuals. The liver which weights approximately 3.5 pounds in an average adult is on the right side of the body (unless an individual is born with their organs reversed). The liver hangs down from the diaphragm by the transverse and falciform ligaments which anchor the proximal attachment sites of the right hemi-diaphragm and help to preserve the area of the right hemidiaphragm known as the right ZOA. The absence of a liver on the L side of the body creates a situation where the L diaphragm is not as well anchored and therefore the area of the diaphragm known as the ZOA can become decreased, the L ribs may become more elevated/externally rotated relative the R side and the L abdominals may become more lengthened relative to

The influence of the asymmetrical pull of the hemi-diaphragms on the ribs can often be seen with visual observation of the anterior inferior rib angle which is often wider on the L than the R and the ribs may appear more protruded on the left side. 54 The asymmetrical distal attachment site of the L (anterior bodies of L1-2) versus R hemidiaphragm (anterior bodies of L1-3) and the inherent difference in the size of the large R central tendon versus the smaller L central tendon contribute to asymmetrical pull of the hemi-diaphragms on the

achieve this aim.

the right side.41, 45

Fig. 5. Sagittal view of the influence of the pull of the diaphragm and psoas (polyarticular chain) on the spine, pelvis and ribs: increased lordosis/extension, hip flexion/anterior pelvic tilt and rib elevation/external rotation.

Copyright © Kyndy Boyle 2007, used with permission

Fig. 5. Sagittal view of the influence of the pull of the diaphragm and psoas (polyarticular chain) on the spine, pelvis and ribs: increased lordosis/extension, hip flexion/anterior

pelvic tilt and rib elevation/external rotation.

Copyright © Kyndy Boyle 2007, used with permission

responses during the ASLR as they attempted to compensate for their lack of ability to transfer load through their lumbopelvic region secondary to suboptimal form and/or force closure. When the ASLR was repeated with manual compression on the subjects with SIJP, their responses normalized: respiratory rate slowed, pelvic floor did not depress and their diaphragm had more excursion. O'Sullivan et al. described three possibilities for their findings. The first possibility was that subjects with SIJP and suboptimal form closure across one or both SIJs may have been a result of a lesion in their ligamentous system which required their diaphragm to be recruited to generate IAP which led to suboptimal respiration. The second possibility was the suboptimal force closure was a result of pain or a motor control deficit that lead to substitution strategies and splinting of the diaphragm which resulted in suboptimal respiration. The third possibility was reasoned as a possible compromise of *both* form and force closure mechanisms. The recommendations that O'Sullivan et al. make in conclusion of their study is that "intervention to integrate control of deep abdominals with the pelvic floor and diaphragm may be effective for patients with SIJP." The authors however do not give any examples of exercises that patients could do to achieve this aim.

A biomechanical theory to explain both R and L sided SIJP was developed by Ron Hruska PT. 45-48 His theory supports the concept of the SIJ functioning as a hip joint and also explains why the right SIJ may move more in the sagittal plane than the L SIJ. Through Hruskas 33 years of full time practice as a physical therapy clinician, he has recognized a common pattern of asymmetry that may contribute to a myriad of musculoskeletal conditions including SIJP/SIJD.45 Other musculoskeletal conditions that the asymmetrical pattern may contribute to include thoracic outlet syndrome,44 low back pain,47, 49 sciatica,46 trochanteric bursitis,50 asthma51, pelvic floor pain and proximal hamstring strain.52 This pattern is called the Left Anterior Interior Chain (L AIC) pattern which gives focus to a polyarticular chain of muscles that is anterior to the spine and interior (deep) in the body, which includes the diaphragm and psoas.45, 53 47 The belief is that this chain of muscles becomes imbalanced because of several factors such as the asymmetrical position of organs, asymmetrical forces exerted by the diaphragm and hemisphere dominance.45 The pattern is thought to manifest in both right handed and L handed individuals. The liver which weights approximately 3.5 pounds in an average adult is on the right side of the body (unless an individual is born with their organs reversed). The liver hangs down from the diaphragm by the transverse and falciform ligaments which anchor the proximal attachment sites of the right hemi-diaphragm and help to preserve the area of the right hemidiaphragm known as the right ZOA. The absence of a liver on the L side of the body creates a situation where the L diaphragm is not as well anchored and therefore the area of the diaphragm known as the ZOA can become decreased, the L ribs may become more elevated/externally rotated relative the R side and the L abdominals may become more lengthened relative to the right side.41, 45

The influence of the asymmetrical pull of the hemi-diaphragms on the ribs can often be seen with visual observation of the anterior inferior rib angle which is often wider on the L than the R and the ribs may appear more protruded on the left side. 54 The asymmetrical distal attachment site of the L (anterior bodies of L1-2) versus R hemidiaphragm (anterior bodies of L1-3) and the inherent difference in the size of the large R central tendon versus the smaller L central tendon contribute to asymmetrical pull of the hemi-diaphragms on the

Conservative Management for Patients with Sacroiliac Joint Dysfunction 303

the left side (i.e. left hemilordosis). Along with this position would be lower lumbar vertebrae and the sacrum oriented in right rotation. The right hip in a closed chain would therefore be in adduction and oriented in internal rotation. The left hip would be in abduction and either neutral in the hip joint (rather than rotated) or in compensatory external rotation to realign the foot in the sagittal plane. The pelvic position of left anterior pelvic tilt (sagittal plane) and forward rotation (transverse plane) compliments the position of right thoracic and left lumbar IAS. (Figure 6) A pelvic position of right APT and forward rotation would not direct the spine

The IAS and L AIC patterns are supported by two Spine Journal articles. Kouwenhoven et al. used CT on 50 subjects to investigate whether or not an inherent pattern of asymmetry of the spine was present in individuals without diagnosed scoliosis..57 He reported right rotation of lumbar-thoracic vertebrae (L5-T5) and L rotation of upper thoracic vertebrae (T3- 4). The opposite pattern was reported in a separate study (N=37) where subjects with organ reversal (situs inversus totalis) were sampled and the same CT measurements were made.58 This inherent pattern was left lumbar rotation (L5-T5) and R upper thoracic rotation (T3-4). These inherent patterns of spinal rotation were attributed to organ placement including the heart. Hruska's identification of the pattern has lead to development of conservative physical therapy management for a myriad of conditions that are believed to relate to it and

Clinicians trained in Postural Restoration often use the Ober's Test to assess triplanar pelvic position.45 If the pelvis is neutral then the leg should be able to adduct at the hip joint below the horizontal. If the pelvis is not neutral (i.e. the acetabulum over the femoral head is not in an anatomical neutral position) then when the leg is moved by the clinician during the test, a bony block may be felt during the external rotation/abduction phase of the test and/or during the adduction phase of the test. The bony block may indicate an abutment of the femoral neck on the cotyloid rim of the acetabulum. An increase in either hip flexor tone may be felt by the clinician during the hip extension phase of the test or an increase in tone of the abductors during the adduction phase of the test are additional possible findings during the Ober's Test. A positive test on the left side is common for patients in a typical L AIC pattern and it is usually interpreted by the clinician as a left anterior tilt and/or left forward rotation of the pelvis.46, 47, 50 A positive test on both the right and left sides is interpreted as a bilateral anterior pelvic tilt which is seen in patients with a Posterior Exterior Chain (PEC), which is discussed at the end of this section (page 14). This use of the test is relatively new and different from the traditional use which is to determine if there is shortness of the iliotibial band/tensor fascia latae.59 Since the use of the Ober's Test by those clinicians trained in Postural Restoration is different in the reason to do the test, the interpretation of a positive test and in the intervention for a positive test, the Postural Restoration InstituteTM began using a new name, the Adduction Drop Test (ADT) to avoid confusion. This ADT test is being used therefore as a reflection of triplanar position of the

The L AIC pattern is thought to relate to SIJ instability in that the pattern leads to over use of the R leg for standing where the center of gravity (COG) is shifted to the right. The COG shifted right would place the R hip into adduction and oriented into internal rotation. The R adductor magnus may become over active (hypertonic) and short. In order to get more internal rotation at the hip in the position of relative hip IR (acetabulum over femur) the

into left lumbar rotation or compensatory right thoracic rotation.

pelvis which does have some preliminary research support.60, 61

this approach is called Postural Restoration.45

spine. Asymmetrical hemidiaphragm on the spine could influence the SIJs along with many other areas of the body. This asymmetrical pattern when severe enough to be ten degrees or more of curvature is commonly known as idiopathic acquired scoliosis (IAS).55 The L AIC pattern therefore compliments the common scoliosis pattern. The pattern of IAS is documented between 85-98% with right thoracic curves rather than left and possibly L lumbar curves rather than right.56 The literature doesn't explain why the right thoracic curves are much more common than L thoracic curves; however the reasoning behind a L AIC pattern does. This reasoning includes the asymmetry of organ placement, asymmetrical pull of the hemi-diaphragms; lateralization of the brain and the direction of pelvic movement influences the direction of vertebral and rib movement. The greater pull of the left hemidiaphragm is thought to contribute to an asymmetrical lumbar-pelvic-sacralfemoral position. This position includes an anterior pelvic tilt and forward pelvic rotation on


Fig. 6. Frontal plane anterior and posterior views of the lower lumbar-pelvic-sacral-femoral position in a Left Anterior Interior Chain Pattern (L AIC) Copyright © Postural Restoration 2007, used with permission

spine. Asymmetrical hemidiaphragm on the spine could influence the SIJs along with many other areas of the body. This asymmetrical pattern when severe enough to be ten degrees or more of curvature is commonly known as idiopathic acquired scoliosis (IAS).55 The L AIC pattern therefore compliments the common scoliosis pattern. The pattern of IAS is documented between 85-98% with right thoracic curves rather than left and possibly L lumbar curves rather than right.56 The literature doesn't explain why the right thoracic curves are much more common than L thoracic curves; however the reasoning behind a L AIC pattern does. This reasoning includes the asymmetry of organ placement, asymmetrical pull of the hemi-diaphragms; lateralization of the brain and the direction of pelvic movement influences the direction of vertebral and rib movement. The greater pull of the left hemidiaphragm is thought to contribute to an asymmetrical lumbar-pelvic-sacralfemoral position. This position includes an anterior pelvic tilt and forward pelvic rotation on

Fig. 6. Frontal plane anterior and posterior views of the lower lumbar-pelvic-sacral-femoral

position in a Left Anterior Interior Chain Pattern (L AIC) Copyright © Postural Restoration 2007, used with permission the left side (i.e. left hemilordosis). Along with this position would be lower lumbar vertebrae and the sacrum oriented in right rotation. The right hip in a closed chain would therefore be in adduction and oriented in internal rotation. The left hip would be in abduction and either neutral in the hip joint (rather than rotated) or in compensatory external rotation to realign the foot in the sagittal plane. The pelvic position of left anterior pelvic tilt (sagittal plane) and forward rotation (transverse plane) compliments the position of right thoracic and left lumbar IAS. (Figure 6) A pelvic position of right APT and forward rotation would not direct the spine into left lumbar rotation or compensatory right thoracic rotation.

The IAS and L AIC patterns are supported by two Spine Journal articles. Kouwenhoven et al. used CT on 50 subjects to investigate whether or not an inherent pattern of asymmetry of the spine was present in individuals without diagnosed scoliosis..57 He reported right rotation of lumbar-thoracic vertebrae (L5-T5) and L rotation of upper thoracic vertebrae (T3- 4). The opposite pattern was reported in a separate study (N=37) where subjects with organ reversal (situs inversus totalis) were sampled and the same CT measurements were made.58 This inherent pattern was left lumbar rotation (L5-T5) and R upper thoracic rotation (T3-4). These inherent patterns of spinal rotation were attributed to organ placement including the heart. Hruska's identification of the pattern has lead to development of conservative physical therapy management for a myriad of conditions that are believed to relate to it and this approach is called Postural Restoration.45

Clinicians trained in Postural Restoration often use the Ober's Test to assess triplanar pelvic position.45 If the pelvis is neutral then the leg should be able to adduct at the hip joint below the horizontal. If the pelvis is not neutral (i.e. the acetabulum over the femoral head is not in an anatomical neutral position) then when the leg is moved by the clinician during the test, a bony block may be felt during the external rotation/abduction phase of the test and/or during the adduction phase of the test. The bony block may indicate an abutment of the femoral neck on the cotyloid rim of the acetabulum. An increase in either hip flexor tone may be felt by the clinician during the hip extension phase of the test or an increase in tone of the abductors during the adduction phase of the test are additional possible findings during the Ober's Test. A positive test on the left side is common for patients in a typical L AIC pattern and it is usually interpreted by the clinician as a left anterior tilt and/or left forward rotation of the pelvis.46, 47, 50 A positive test on both the right and left sides is interpreted as a bilateral anterior pelvic tilt which is seen in patients with a Posterior Exterior Chain (PEC), which is discussed at the end of this section (page 14). This use of the test is relatively new and different from the traditional use which is to determine if there is shortness of the iliotibial band/tensor fascia latae.59 Since the use of the Ober's Test by those clinicians trained in Postural Restoration is different in the reason to do the test, the interpretation of a positive test and in the intervention for a positive test, the Postural Restoration InstituteTM began using a new name, the Adduction Drop Test (ADT) to avoid confusion. This ADT test is being used therefore as a reflection of triplanar position of the pelvis which does have some preliminary research support.60, 61

The L AIC pattern is thought to relate to SIJ instability in that the pattern leads to over use of the R leg for standing where the center of gravity (COG) is shifted to the right. The COG shifted right would place the R hip into adduction and oriented into internal rotation. The R adductor magnus may become over active (hypertonic) and short. In order to get more internal rotation at the hip in the position of relative hip IR (acetabulum over femur) the

Conservative Management for Patients with Sacroiliac Joint Dysfunction 305

acetabulum when the pelvis goes anterior and forward it would appear to be oriented inward with toes pointing inward to the midline. This position often results in compensatory L hip external rotation (ER) to reorient the foot on the ground and the femur back into the sagittal plane.45, 62, 63 When the L hip external rotators become over active because of this compensatory L hip position, the L hip is in abduction and external rotation (ER). The L ilium may begin to function as a L hip joint to increase the available hip ROM

Fig. 8. Compensatory left hip external rotation (ER) associated with a L AIC pattern

femur (F) moves on the left acetabulum (A), therefore left FA ER.

Copyright © Kyndy Boyle 2007, used with permission

resulting in over lengthening/laxity of the iliofemoral and pubofemoral ligaments. The left

ilium would have to attempt forward motion which would cause tensile forces across the posterior SIJ. A gap or greater distance between the ilium and sacrum is seen on a MRI for a patient who was seeking physical therapy for her R SIJP. (Figure 7) Therefore, if the R SIJ begins to move too much it may become painful. If however the ligaments and muscles are stable and strong and continue to provide enough stability to the right SIJ to avoid pain, it is possible that the R hip joint itself may begin to move too much, but in a faulty position of the acetabulum over the femur. This situation may lead to anterior medial hip impingement commonly referred to as femoral-acetabular impingement (FAI).62 It is possible as evidenced by my personal experience, to improve a patient's R SIJ stability with therapeutic exercise and then if discharged too early, the patient may begin to complain of R hip impingement.

Fig. 7. Transverse plane view of the Sacroiliac Joints on Magnetic Resonance Imaging (MRI). The image shows a greater opening/gapping on the right side. Copyright © Postural Restoration Institute™ used with permission, www.posturalrestoration.com

The pelvic position with this L AIC pattern is thought to result in part from the asymmetrical pull on the spine by the diaphragm and also from the weaker L abdominals which would result in an anterior tilt and forward rotation of the L innominate relative to the R and sacrum orientation to the right.20, 45, 47 If the L femur stays neutral in the

ilium would have to attempt forward motion which would cause tensile forces across the posterior SIJ. A gap or greater distance between the ilium and sacrum is seen on a MRI for a patient who was seeking physical therapy for her R SIJP. (Figure 7) Therefore, if the R SIJ begins to move too much it may become painful. If however the ligaments and muscles are stable and strong and continue to provide enough stability to the right SIJ to avoid pain, it is possible that the R hip joint itself may begin to move too much, but in a faulty position of the acetabulum over the femur. This situation may lead to anterior medial hip impingement commonly referred to as femoral-acetabular impingement (FAI).62 It is possible as evidenced by my personal experience, to improve a patient's R SIJ stability with therapeutic exercise and then if discharged too early, the patient may begin to complain of R hip impingement.

Fig. 7. Transverse plane view of the Sacroiliac Joints on Magnetic Resonance Imaging (MRI).

The pelvic position with this L AIC pattern is thought to result in part from the asymmetrical pull on the spine by the diaphragm and also from the weaker L abdominals which would result in an anterior tilt and forward rotation of the L innominate relative to the R and sacrum orientation to the right.20, 45, 47 If the L femur stays neutral in the

The image shows a greater opening/gapping on the right side. Copyright © Postural Restoration Institute™ used with permission,

www.posturalrestoration.com

acetabulum when the pelvis goes anterior and forward it would appear to be oriented inward with toes pointing inward to the midline. This position often results in compensatory L hip external rotation (ER) to reorient the foot on the ground and the femur back into the sagittal plane.45, 62, 63 When the L hip external rotators become over active because of this compensatory L hip position, the L hip is in abduction and external rotation (ER). The L ilium may begin to function as a L hip joint to increase the available hip ROM

Fig. 8. Compensatory left hip external rotation (ER) associated with a L AIC pattern resulting in over lengthening/laxity of the iliofemoral and pubofemoral ligaments. The left femur (F) moves on the left acetabulum (A), therefore left FA ER. Copyright © Kyndy Boyle 2007, used with permission

Conservative Management for Patients with Sacroiliac Joint Dysfunction 307

obliques, erector spinae, quadratus lumborum (QL), hip adductors and hip abductor exercises. Again the specific ways the exercises were done including dosage parameters were not described. The outcome measure was taken at initial, 20 weeks, one year, and two years. The EG had superior outcomes for reducing pain as measured by the Visual Analog Scale (VAS), improved function as measured by the ODI, and improved quality

Published case series have been reported with some improvements in pain and function. Osterbauer investigated chiropractic manipulation on ten subjects with positive provocation testing and were followed for 18 visits over six weeks.67 The improvements in function (ODI) and pain (VAS) were reported at six weeks and one year. Hall was a physical therapist who reported on a case series of two who had a positive ASLR test and positive provocation tests. These subjects were managed with muscle energy techniques, TA and multifidus activation, isometric hip abduction/adduction, activation of lats, GM and abdominal crunches. They were also instructed in the use of a SIJ belt. These subjects were seen from five to seven visits over seven to ten weeks. Function significantly improved based on the ODI, however pain did not significantly improve using a numeric pain rating

O'Sullivan reported on a case series of nine subjects with SIJP with positive ASLR tests and provocation tests who were instructed in TA, IO and pelvic floor (PF) activation in a neutral spine in various positions: supine, sitting, sit to stand, standing, single leg stance and walking.28 Outcomes included suboptimal movement of the pelvic floor, diaphragm and suboptimal respiration and disability. These outcomes were discussed earlier under the

Two case studies were reported by O'Sullivan to highlight one patient with reduced force closure and one patient with excessive force closure. The female patient with R SIJP had reduced force closure based on a positive ASLR with breath holding and positive provocation testing. She was instructed in TA and pelvic floor activation without breath holding, while maintaining optimal spinal alignment and neutral posture in sitting, standing and lifting. She was also instructed in lunges, squats, aerobic exercise including bicycling and walking and patient education in the vicious pain cycle. At one year after discharge, O'Sullivan reported that she returned to work and to playing handball, however no formal outcome measures were used or reported. The other patient suffered from right more than left SIJP as a result of excessive force closure as measured by a negative ASLR, positive provocation testing and inability to relax her pelvic floor muscles based on an internal exam. This patient was educated in the vicious pain cycle and the need for pelvic floor muscle inhibition. She was instructed in relaxation strategies for muscles and anxiety in sitting, standing and activities of daily living (ADLs) including breathing and rest breaks. She was also referred to a psychologist and at one year, O'Sullivan noted that she experienced "little pain or disability." Again, no formal outcome measures were used or

A case study published by Painter discussed a patient with a positive ASLR and positive provocation testing who was managed with pelvic floor and TA activation during ADLs,

of life as measured by the SF-36.65

scale (NPRS).

reported.

section of respiration and SIJP.

and the left SIJ may become unstable. If however, the excessive motion occurs at the hip rather the L SIJ, the anterior hip ligaments/capsule (pubofemoral and iliofemoral ligaments) may become stretched out and loose creating instability of the L anterior hip and may be associated with L anterior superior hip impingement.64 (Figure 8)

A pattern that may overlay a L AIC pattern is called a Posterior Exterior Chain (PEC) pattern.45, 48 The PEC terminology is used for a patient who has a bilateral anterior pelvic tilt and excessive lumbar lordosis as a result of over activity of muscles in the posterior back. The muscles that make up the PEC include the latissimus dorsi, quadrates lumborum, posterior intercostals, serratus posterior and ilocostalis lumborum.48 These patients often have the inability to touch their toes, and/or reverse the extension/lordosis curvature of their spines. They may also lack the ability to do a full squat. Management of patients with a PEC pattern associated with SIJP and specific management and clinical reasoning for patients with SIJP on the right versus the left SIJ will be discussed toward the end of this chapter.

#### **4. Traditional interventions for SIJP/SIJD**

Interventions specifically for SIJP/SIJD (rather than general PGP) that appear in peerreviewed literature include SIJ manipulation, muscle energy techniques, SIJ belt, patient education regarding the pain cycle, moist heat, soft tissue massage, electrical stimulation and therapeutic exercise including activation of the transverse abdominus, stretching exercises and aquatics. In spite of the prevalence of patients with SIJP/SIJD and the relatively long length of time of recognition of SIJ conditions, there is a paucity of published literature. Furthermore, published literature pertaining to the SIJs is primarily in the bottom half of the evidence pyramid. The good news however is that all of the listed interventions have shown to reduce pain and disability to varying degrees. The challenge is that the authors do not always describe the therapeutic exercise so the results are difficult to interpret and the studies are not replicable. With the exception of two randomized controlled trials (RCT), readers are not able to infer cause and effect with the existing studies. Lastly, Stuge believes that interventions should be based on a theoretical framework. 65

A RCT published by Chiropractors investigated two different types of chiropractic manipulation for the SIJ: manual versus mechanical (with a piece of equipment). The Chiropractors studied 60 subjects using diagnostic criteria of a painful sulcus on palpation and a positive provocation test. They were treated for four visits over two weeks and function was measured with an Oswestry Disability Index (ODI) at the initial visit and three weeks post intervention. There were no differences between groups.66 Stuge et al published the results of an RCT done on 81 subjects with PGP post partum with a positive ASLR and a positive provocation test. They studied two groups: the control group (CG) received "general interventions" that included massage, relaxation, joint mobilization, manipulation, electrical stimulation, hot packs and strengthening exercises. Specific parameters of the interventions including dosage and the specific exercises used were not described. The exercise group received all the treatments as the CG plus instruction in TA , multifidus, gluteus maximus (GM), latissimus dorsi (lats),

and the left SIJ may become unstable. If however, the excessive motion occurs at the hip rather the L SIJ, the anterior hip ligaments/capsule (pubofemoral and iliofemoral ligaments) may become stretched out and loose creating instability of the L anterior hip and may be

A pattern that may overlay a L AIC pattern is called a Posterior Exterior Chain (PEC) pattern.45, 48 The PEC terminology is used for a patient who has a bilateral anterior pelvic tilt and excessive lumbar lordosis as a result of over activity of muscles in the posterior back. The muscles that make up the PEC include the latissimus dorsi, quadrates lumborum, posterior intercostals, serratus posterior and ilocostalis lumborum.48 These patients often have the inability to touch their toes, and/or reverse the extension/lordosis curvature of their spines. They may also lack the ability to do a full squat. Management of patients with a PEC pattern associated with SIJP and specific management and clinical reasoning for patients with SIJP on the right versus the left SIJ will be discussed toward the end of this

Interventions specifically for SIJP/SIJD (rather than general PGP) that appear in peerreviewed literature include SIJ manipulation, muscle energy techniques, SIJ belt, patient education regarding the pain cycle, moist heat, soft tissue massage, electrical stimulation and therapeutic exercise including activation of the transverse abdominus, stretching exercises and aquatics. In spite of the prevalence of patients with SIJP/SIJD and the relatively long length of time of recognition of SIJ conditions, there is a paucity of published literature. Furthermore, published literature pertaining to the SIJs is primarily in the bottom half of the evidence pyramid. The good news however is that all of the listed interventions have shown to reduce pain and disability to varying degrees. The challenge is that the authors do not always describe the therapeutic exercise so the results are difficult to interpret and the studies are not replicable. With the exception of two randomized controlled trials (RCT), readers are not able to infer cause and effect with the existing studies. Lastly, Stuge believes that interventions should be based on a theoretical

A RCT published by Chiropractors investigated two different types of chiropractic manipulation for the SIJ: manual versus mechanical (with a piece of equipment). The Chiropractors studied 60 subjects using diagnostic criteria of a painful sulcus on palpation and a positive provocation test. They were treated for four visits over two weeks and function was measured with an Oswestry Disability Index (ODI) at the initial visit and three weeks post intervention. There were no differences between groups.66 Stuge et al published the results of an RCT done on 81 subjects with PGP post partum with a positive ASLR and a positive provocation test. They studied two groups: the control group (CG) received "general interventions" that included massage, relaxation, joint mobilization, manipulation, electrical stimulation, hot packs and strengthening exercises. Specific parameters of the interventions including dosage and the specific exercises used were not described. The exercise group received all the treatments as the CG plus instruction in TA , multifidus, gluteus maximus (GM), latissimus dorsi (lats),

associated with L anterior superior hip impingement.64 (Figure 8)

**4. Traditional interventions for SIJP/SIJD** 

chapter.

framework. 65

obliques, erector spinae, quadratus lumborum (QL), hip adductors and hip abductor exercises. Again the specific ways the exercises were done including dosage parameters were not described. The outcome measure was taken at initial, 20 weeks, one year, and two years. The EG had superior outcomes for reducing pain as measured by the Visual Analog Scale (VAS), improved function as measured by the ODI, and improved quality of life as measured by the SF-36.65

Published case series have been reported with some improvements in pain and function. Osterbauer investigated chiropractic manipulation on ten subjects with positive provocation testing and were followed for 18 visits over six weeks.67 The improvements in function (ODI) and pain (VAS) were reported at six weeks and one year. Hall was a physical therapist who reported on a case series of two who had a positive ASLR test and positive provocation tests. These subjects were managed with muscle energy techniques, TA and multifidus activation, isometric hip abduction/adduction, activation of lats, GM and abdominal crunches. They were also instructed in the use of a SIJ belt. These subjects were seen from five to seven visits over seven to ten weeks. Function significantly improved based on the ODI, however pain did not significantly improve using a numeric pain rating scale (NPRS).

O'Sullivan reported on a case series of nine subjects with SIJP with positive ASLR tests and provocation tests who were instructed in TA, IO and pelvic floor (PF) activation in a neutral spine in various positions: supine, sitting, sit to stand, standing, single leg stance and walking.28 Outcomes included suboptimal movement of the pelvic floor, diaphragm and suboptimal respiration and disability. These outcomes were discussed earlier under the section of respiration and SIJP.

Two case studies were reported by O'Sullivan to highlight one patient with reduced force closure and one patient with excessive force closure. The female patient with R SIJP had reduced force closure based on a positive ASLR with breath holding and positive provocation testing. She was instructed in TA and pelvic floor activation without breath holding, while maintaining optimal spinal alignment and neutral posture in sitting, standing and lifting. She was also instructed in lunges, squats, aerobic exercise including bicycling and walking and patient education in the vicious pain cycle. At one year after discharge, O'Sullivan reported that she returned to work and to playing handball, however no formal outcome measures were used or reported. The other patient suffered from right more than left SIJP as a result of excessive force closure as measured by a negative ASLR, positive provocation testing and inability to relax her pelvic floor muscles based on an internal exam. This patient was educated in the vicious pain cycle and the need for pelvic floor muscle inhibition. She was instructed in relaxation strategies for muscles and anxiety in sitting, standing and activities of daily living (ADLs) including breathing and rest breaks. She was also referred to a psychologist and at one year, O'Sullivan noted that she experienced "little pain or disability." Again, no formal outcome measures were used or reported.

A case study published by Painter discussed a patient with a positive ASLR and positive provocation testing who was managed with pelvic floor and TA activation during ADLs,

Conservative Management for Patients with Sacroiliac Joint Dysfunction 309

Fig. 9. Standing Un-resisted Wall Reach

mid-back down is flat on the wall. 4. Squat down slightly as you squeeze the ball.

8. Exhale and reach further forward.

down on the wall. 11. Relax and repeat 4 more times.

www.posturalrestoration.com

1. Stand facing away from a wall and place your heels 7-10 inches away from the wall. 2. Stand up straight with a ball between your knees and feet shoulder width apart.

5. Keeping your mid-back down on the wall, inhale through your nose.

expand your upper back (feel a stretch in your upper back).

Copyright © Postural Restoration Institute™ used with permission,

wall (mid-back down should stay flat on the wall).

9. Repeat this breathing sequence for 4-5 deep breaths.

3. Bring your arms out in front of you as you round out your back, performing a pelvic tilt so your

6. As you exhale through your mouth, reach your arms forward so your upper back comes off the

7. Hold your arms steadily in this position (reach), as you inhale through your nose again and

10. Slowly stand up by pushing through your heels and slide up the wall, keeping your mid-back

bridges, lunges, prone exercise over a physioball with alternating upper extremity flexion and lower extremity hip extension, abdominal crunches on a physioball, aquatic exercises and the use of a SIJ belt. The patient was seen for seven visits over three weeks and was reported to have returned to "full activity" with no "stress urinary incontinence" at six weeks. No formal outcome measure was used or reported.

A descriptive report was published by Sasso on 69 subjects with SIJ pain based on symptoms occurring in Fortin's area.68 SIJ mobilizations were performed but not described, and strengthening of "muscular stabilizers and abdominals" were reported but not described in any detail. Patient education included instruction by the clinician in proper lifting technique and "activity modification." Outcomes were reported with the use of a survey at two years. Ninety-five percent of subjects reported their outcome as good or excellent and five percent reported their outcome as fair or poor.

The use of a SIJ belt has been used as one part of the intervention for reported patients/subjects with SIJP/SIJD to aid in force closure of the SIJ passively. One study included the investigation of the best placement of the SIJ belt to achieve the greatest decrease in SIJ ligamentous laxity. Placement just below the ASIS was reported as better than at the level of the pubic symphysis. 25 Damen also investigated how much force was best to decrease SIJ ligamentous laxity by using Doppler Imaging of Vibrations technology to assess ligamentous stiffness. Damen used a strain gauge in the belt for ten females 18-39 years of age without SIJP. Damen reported that either 50 Newtons or 100 Newtons achieved the same benefit.25

#### **5. Specific Postural Restoration interventions for a PEC pattern relating to right and/or left SIJP**

Postural Restoration therapeutic exercises (also known as non-manual techniques) can be used for all patients who suffer from pain in their right, left or bilateral SIJs. This chapter will include a description for management of patients who present with bilateral anterior pelvic tilt/PEC pattern followed by a description for management of patients who present with a L AIC pattern and right SIJP followed by those who present with compensation for a L AIC pattern and left SIJP. Clinical reasoning for a patient with a PEC pattern is to restore the ability of the patient to flex their spine and expand their posterior mediastinum as evidenced by the ability to easily touch their toes (without the use of a hamstring lengthening/stretching program) and the ability to fully squat comfortably while breathing. Exercises that may be used include a Standing Unresisted Wall Reach, Standing Resisted Wall Reach, Reverse Door Squat (with or without the assistance of a pole to hold on too) or a Wall Short Seated Reach. (Figures 9-12) The Unresisted Wall Reach may be enough to achieve spinal flexion and posterior mediastinum expansion, however some patients may need more abdominal recruitment to achieve the results, therefore the Resisted Wall Reach may be more beneficial. Some patients may have pain in their knee/s or back and therefore are unable to do either of the standing wall reach exercises or the squat exercise. In that case, the Wall Short Seated Reach may be a good option. Once the patient's sagittal plane motion and ability is restored, the patient is managed for the underlying L AIC pattern depending on the side of involvement.

bridges, lunges, prone exercise over a physioball with alternating upper extremity flexion and lower extremity hip extension, abdominal crunches on a physioball, aquatic exercises and the use of a SIJ belt. The patient was seen for seven visits over three weeks and was reported to have returned to "full activity" with no "stress urinary incontinence" at six

A descriptive report was published by Sasso on 69 subjects with SIJ pain based on symptoms occurring in Fortin's area.68 SIJ mobilizations were performed but not described, and strengthening of "muscular stabilizers and abdominals" were reported but not described in any detail. Patient education included instruction by the clinician in proper lifting technique and "activity modification." Outcomes were reported with the use of a survey at two years. Ninety-five percent of subjects reported their outcome as good or

The use of a SIJ belt has been used as one part of the intervention for reported patients/subjects with SIJP/SIJD to aid in force closure of the SIJ passively. One study included the investigation of the best placement of the SIJ belt to achieve the greatest decrease in SIJ ligamentous laxity. Placement just below the ASIS was reported as better than at the level of the pubic symphysis. 25 Damen also investigated how much force was best to decrease SIJ ligamentous laxity by using Doppler Imaging of Vibrations technology to assess ligamentous stiffness. Damen used a strain gauge in the belt for ten females 18-39 years of age without SIJP. Damen reported that either 50 Newtons or 100 Newtons achieved

**5. Specific Postural Restoration interventions for a PEC pattern relating to** 

Postural Restoration therapeutic exercises (also known as non-manual techniques) can be used for all patients who suffer from pain in their right, left or bilateral SIJs. This chapter will include a description for management of patients who present with bilateral anterior pelvic tilt/PEC pattern followed by a description for management of patients who present with a L AIC pattern and right SIJP followed by those who present with compensation for a L AIC pattern and left SIJP. Clinical reasoning for a patient with a PEC pattern is to restore the ability of the patient to flex their spine and expand their posterior mediastinum as evidenced by the ability to easily touch their toes (without the use of a hamstring lengthening/stretching program) and the ability to fully squat comfortably while breathing. Exercises that may be used include a Standing Unresisted Wall Reach, Standing Resisted Wall Reach, Reverse Door Squat (with or without the assistance of a pole to hold on too) or a Wall Short Seated Reach. (Figures 9-12) The Unresisted Wall Reach may be enough to achieve spinal flexion and posterior mediastinum expansion, however some patients may need more abdominal recruitment to achieve the results, therefore the Resisted Wall Reach may be more beneficial. Some patients may have pain in their knee/s or back and therefore are unable to do either of the standing wall reach exercises or the squat exercise. In that case, the Wall Short Seated Reach may be a good option. Once the patient's sagittal plane motion and ability is restored, the patient is managed for the underlying L AIC pattern depending

weeks. No formal outcome measure was used or reported.

excellent and five percent reported their outcome as fair or poor.

the same benefit.25

**right and/or left SIJP** 

on the side of involvement.

Fig. 9. Standing Un-resisted Wall Reach


Conservative Management for Patients with Sacroiliac Joint Dysfunction 311

1. Stand in front of an open doorway and place a wooden pole in front of the door frame at or below

2. Hold onto the pole and find the best functional squat position (bottom of pelvis to heel cords) while keeping your heels down and knees inside your elbows. You may need to stand back up

3. Once you have positioned yourself in the most optimal squat position, take a deep breath in through your nose and fill the back of your chest wall with air while keeping your eyes up or level with the floor. Exhale through your mouth as you lean back until all your air is out. Repeat this sequence of inhalation and exhalation 3 to 4 more times always allowing your heel cords, front of

4. After the fourth breath in, exhale and begin to stand up pushing down through your heels and keeping your back rounded while sliding the pole up the door frame as necessary to assist you in

6. The goal is to perform the first 3 steps above with the pole at the level of your ankle, with your elbows straight, with your knees in your chest and with the bottom of your pelvis on your heel

Once you've achieved the above goal, repeat the first three steps. After the fourth breathe in, reach forward with your hands as you exhale so that the pole loses contact with the door frame. As you exhale also begin to stand up pushing through your heels and continuing to reach forward so that the

and re-position your feet so you can get your bottom down as far as allowed.

your thighs/knees and your back muscles to relax and stretch.

Copyright © Postural Restoration Institute™ used with permission,

5. Lower the pole and repeat the process 4 more times.

cords (PRI Squat Level Four or Five).

pole doesn't touch the door frame.

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Fig. 11. Reverse Door Squat

standing knee height.

coming up.

Fig. 10. Standing Resisted Wall Reach


Fig. 11. Reverse Door Squat

Fig. 10. Standing Resisted Wall Reach

8. Inhale through your nose.

14. Relax and repeat 4 more times.

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engaged.

1. Place tubing securely in door slightly below shoulder level. 2. Stand with your heels 7-10 inches away from the wall.

11. Exhale and reach forward further with your arms.

3. Stand up straight with a ball between your knees and feet lined up with each other. 4. Place your hands through the loops of the tubing with your palms facing down.

10. Hold arms steadily in this position as you inhale again and expand your back.

12. Complete 2 more breaths in and out reaching further each time you exhale.

Copyright © Postural Restoration Institute™ used with permission,

5. Straighten your arms out in front of you and round your back, engaging your abdominals. 6. Once you can feel your abdominals working begin to squat as you squeeze the ball. 7. Squat down until your bottom touches the wall (do not fall back into wall).

9. As you exhale through your mouth reach forward and downward as your back stays rounded.

13. Stand up while keeping arms straight, back rounded, abdominals and inner thigh muscles


Once you've achieved the above goal, repeat the first three steps. After the fourth breathe in, reach forward with your hands as you exhale so that the pole loses contact with the door frame. As you exhale also begin to stand up pushing through your heels and continuing to reach forward so that the pole doesn't touch the door frame.

Conservative Management for Patients with Sacroiliac Joint Dysfunction 313

Clinical reasoning used by clinicians trained in Postural Restoration to manage right SIJP/instability, is to optimize lumbar-pelvic-femoral position and train the patient to maintain it. This is achieved most commonly by therapeutic exercise instruction/prescription such as right GM activation in the transverse plane that emphasizes normal breathing through the exercise (to avoid breath holding/splinting of the diaphragm) and patient education in positional guidelines during activities of daily living (ADLs). The positional guidelines attempt to oppose the L AIC pattern (e.g. maintain weight over left leg, maintain desired hip positions) during common activities such as sit to stand, sleeping, standing etc.

Therapeutic exercises that activate specific muscles on specific sides of the body and train a patient in different phases of gait to achieve for example, single leg stance control are often used. Exercises with the patient in a sidelying or supine position are usually done initially until motor control with the correct muscles is achieved. After the patient demonstrates mastery of correct position and muscle activation, exercises may be advanced to a standing position. These exercises are also designed for the patient to be able to eventually maintain stability without compensation. SIJP occurring on the right side is thought to occur because of too much motion across the posterior right SIJ. Based on the L AIC pattern, the right hip is often positioned in IR and adduction. Therefore, to achieve optimal lumbar-pelvic-femoral position the goal would be to achieve right hip ER, specifically right acetabulum over femur (AF) ER with concomitant left hip IR, specifically acetabulum motion over the femoral head (L AF IR). The right GM can be considered an important muscle for both form and force closure. The right GM can correct right hip IR in a transverse plane via its action as a powerful external rotator which may contribute to repositioning the sacrum from a position of orientation in right rotation toward neutral (i.e. form closure). The GM is also an effective muscle to restore force closure across the SIJ. There are currently no therapeutic exercises to activate the GM in the transverse plane in published literature relating to management of patients with SIJP

outside of those related to Postural Restoration and developed by Ron Hruska PT.

AF IR and R AF ER with stability offered at the feet by the wall. (Figure 18)

The GM can be activated in the transverse plane in several patient positions: sidelying, supine hooklying and supine with the hips and knees at 90 degrees. In a sidelying position, the GM can be activated in the transverse plane against gravity with or without a band (fit loop) for resistance. (Figure 16) Sagittal plane position of the trunk/spine can be monitored to avoid excessive lumbar lordosis and the feet can rest over a small bolster and press against a wall to gain distal stability and to serve as a fulcrum for the motion and place the right hip into more IR which allows for more ER ROM during the movement of the right leg during the exercise. In a supine position, the right GM is again activated in the transverse plane usually with resistance (fit loop) around both femurs. (Figure 17) To avoid excessive lordosis or over activity of paraspinals the patient moves into a posterior pelvic tilt first with an exhalation and maintains that position throughout the exercise. The left hip can actively be moved into L AF IR which puts both the left and right hips into the desired positions based on the L AIC pattern. R AF ER is not only the desired position; it also shortens the GM positionally before further shortening through FA ER against the resistance of the fit loop. The supine 90/90 position is essentially the same as the supine hooklying position as the right GM is activated in the transverse plane against resistance after the patient moves into L

**5.1 Right sacroiliac joint pain/dysfunction related to a left anterior interior chain** 

**pattern** 

(Figures 13-15)

Fig. 12. Wall Short Seated Reach


1. Sit on the ground with your mid to low back flat against a wall and legs straight out in front of you. 2. Bring your knees as close to your chest as possible by bending your legs one at a time. Keep your

4. Keeping your back on the wall from bra-line to belt-line, slowly exhale through your mouth and

5. Maintaining the position, inhale again through your nose and concentrate on filling the back of

7. Continue in this manner for 4 breaths in and 3 breaths out pausing 3 seconds before each inhalation.

knees together and feet slightly apart. Do not allow your legs to rotate outward.

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reach forward with both arms. Your arms may rest on your knees. Pause 3 seconds.

Fig. 12. Wall Short Seated Reach

3. Inhale through your nose.

your chest wall with air.

8. Relax and repeat 4 more times.

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6. Exhale and reach forward further with your arms.

#### **5.1 Right sacroiliac joint pain/dysfunction related to a left anterior interior chain pattern**

Clinical reasoning used by clinicians trained in Postural Restoration to manage right SIJP/instability, is to optimize lumbar-pelvic-femoral position and train the patient to maintain it. This is achieved most commonly by therapeutic exercise instruction/prescription such as right GM activation in the transverse plane that emphasizes normal breathing through the exercise (to avoid breath holding/splinting of the diaphragm) and patient education in positional guidelines during activities of daily living (ADLs). The positional guidelines attempt to oppose the L AIC pattern (e.g. maintain weight over left leg, maintain desired hip positions) during common activities such as sit to stand, sleeping, standing etc. (Figures 13-15)

Therapeutic exercises that activate specific muscles on specific sides of the body and train a patient in different phases of gait to achieve for example, single leg stance control are often used. Exercises with the patient in a sidelying or supine position are usually done initially until motor control with the correct muscles is achieved. After the patient demonstrates mastery of correct position and muscle activation, exercises may be advanced to a standing position. These exercises are also designed for the patient to be able to eventually maintain stability without compensation. SIJP occurring on the right side is thought to occur because of too much motion across the posterior right SIJ. Based on the L AIC pattern, the right hip is often positioned in IR and adduction. Therefore, to achieve optimal lumbar-pelvic-femoral position the goal would be to achieve right hip ER, specifically right acetabulum over femur (AF) ER with concomitant left hip IR, specifically acetabulum motion over the femoral head (L AF IR). The right GM can be considered an important muscle for both form and force closure. The right GM can correct right hip IR in a transverse plane via its action as a powerful external rotator which may contribute to repositioning the sacrum from a position of orientation in right rotation toward neutral (i.e. form closure). The GM is also an effective muscle to restore force closure across the SIJ. There are currently no therapeutic exercises to activate the GM in the transverse plane in published literature relating to management of patients with SIJP outside of those related to Postural Restoration and developed by Ron Hruska PT.

The GM can be activated in the transverse plane in several patient positions: sidelying, supine hooklying and supine with the hips and knees at 90 degrees. In a sidelying position, the GM can be activated in the transverse plane against gravity with or without a band (fit loop) for resistance. (Figure 16) Sagittal plane position of the trunk/spine can be monitored to avoid excessive lumbar lordosis and the feet can rest over a small bolster and press against a wall to gain distal stability and to serve as a fulcrum for the motion and place the right hip into more IR which allows for more ER ROM during the movement of the right leg during the exercise. In a supine position, the right GM is again activated in the transverse plane usually with resistance (fit loop) around both femurs. (Figure 17) To avoid excessive lordosis or over activity of paraspinals the patient moves into a posterior pelvic tilt first with an exhalation and maintains that position throughout the exercise. The left hip can actively be moved into L AF IR which puts both the left and right hips into the desired positions based on the L AIC pattern. R AF ER is not only the desired position; it also shortens the GM positionally before further shortening through FA ER against the resistance of the fit loop. The supine 90/90 position is essentially the same as the supine hooklying position as the right GM is activated in the transverse plane against resistance after the patient moves into L AF IR and R AF ER with stability offered at the feet by the wall. (Figure 18)

Conservative Management for Patients with Sacroiliac Joint Dysfunction 315

Fig. 14. Positional recommendation in a standing left hip (acetabulum over femur) internal

When standing, place your right foot ahead of your left and attempt to keep your body

rotation (L AF IR) position with center of gravity shifted to the left.

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weight shifted to the left.

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Fig. 13. Positional recommendations for sitting in a left hip (acetabulum over femur) internal rotation (L AF IR) position

When in a seated position attempt to keep your trunk rounded and your knees at or above hip level.

For increased comfort place a small bolster underneath your left thigh and shift your left knee back.

Fig. 13. Positional recommendations for sitting in a left hip (acetabulum over femur) internal

When in a seated position attempt to keep your trunk rounded and your knees at or above

For increased comfort place a small bolster underneath your left thigh and shift your left

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rotation (L AF IR) position

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hip level.

knee back.

Fig. 14. Positional recommendation in a standing left hip (acetabulum over femur) internal rotation (L AF IR) position with center of gravity shifted to the left.

When standing, place your right foot ahead of your left and attempt to keep your body weight shifted to the left.

Conservative Management for Patients with Sacroiliac Joint Dysfunction 317

Fig. 16. Left Sidelying Right Glute Max

your right outside hip engage.

7. Relax and repeat 4 more times.

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mouth.

1. Lie on your left side with your hips and knees bent at a 60-90 degree angle. 2. Place your ankles on top of a 3-5 inch bolster and place your feet firmly on a wall.

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4. Shift your right hip forward until you feel a slight stretch or pull in your left outside hip.

5. Keeping your toes on the wall, raise your right knee keeping it shifted forward. You should feel

6. Hold this position while you take 4-5 deep breaths in through your nose and out through your

3. Place tubing around both thighs slightly above your knees.

Fig. 15. Positional recommendations for sleeping with pillow support and L AF IR Place a pillow between your legs when on either side. Place a pillow under your left side when lying on your left side. Use one-two pillows under your head to keep your head and neck relaxed.

Fig. 15. Positional recommendations for sleeping with pillow support and L AF IR Place a pillow between your legs when on either side. Place a pillow under your left side when lying on your left side. Use one-two pillows under your head to keep your head and

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neck relaxed.

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#### Fig. 16. Left Sidelying Right Glute Max


Conservative Management for Patients with Sacroiliac Joint Dysfunction 319

1. Lie on your back with your feet on a wall and your knees and hips bent at a 90-degree angle. 2. Place tubing around your thighs (just below your knees) and a 4-5 inch ball between your ankles. 3. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your

4. Maintaining a pelvic tilt, shift your left knee down as your left pelvis drops and your right pelvis raises and turns to the left. You should feel the muscles on the outside of your right hip engage.

7. Hold position while you take 4-5 deep breaths in through your nose and out through your mouth.

The L AIC pattern commonly involves over activity and possibly shortness of the right adductors which contribute to or are a result of the right hip IR/adduction seen with a L AIC pattern. If it is determined by the clinician that the adductors are over active/short a therapeutic exercise to inhibit/lengthen the right adductors may be prescribed. (Figure 19) An example of an upright exercise that facilitates activation of the R GM and a left hip position of L AF IR is the Single Leg Wall Left AF IR with Right Glute Max. This exercise is developed to oppose the typical L AIC pattern via activation of the R GM in a transverse plane, while weight bearing on the left leg in a hip position of L AF IR. (Figure 20) To summarize, management of R SIJP associated with a L AIC pattern includes a focus on R GM activation in a transverse plane with desired hip positions (R AF ER and L AF IR) that oppose the positions commonly seen in the L AIC pattern, and right adductor

tailbone is raised slightly off the mat. Keep your back flat on the mat.

5. Squeeze your left ankle into the ball feeling your left inner thigh engage.

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Fig. 18. Supine Right Glute Max with Right AF ER

6. Attempt to lift left heel off of the wall.

Relax and repeat 4 more times.

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inhibition/lengthening as needed.

#### Fig. 17. Supine Hooklying Right Glute Max with R AF ER


Fig. 17. Supine Hooklying Right Glute Max with R AF ER

7. Relax and repeat 4 more times.

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1. Lie on your back and place your feet on a 2-inch block against the wall. 2. Place a band around your knees and a ball between your ankles.

tailbone is raised slightly off the mat. Keep your back flat on the mat. 4. Shift your left knee down. You should feel your left inner thigh engage. 5. Turn your right leg out. You should feel your right outside hip engage.

Copyright © Postural Restoration Institute™ used with permission,

3. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your

6. Hold this position while you take 4-5 breaths in through your nose and out through your mouth.

Fig. 18. Supine Right Glute Max with Right AF ER


 Copyright © Postural Restoration Institute™ used with permission www.posturalrestoration.com

The L AIC pattern commonly involves over activity and possibly shortness of the right adductors which contribute to or are a result of the right hip IR/adduction seen with a L AIC pattern. If it is determined by the clinician that the adductors are over active/short a therapeutic exercise to inhibit/lengthen the right adductors may be prescribed. (Figure 19) An example of an upright exercise that facilitates activation of the R GM and a left hip position of L AF IR is the Single Leg Wall Left AF IR with Right Glute Max. This exercise is developed to oppose the typical L AIC pattern via activation of the R GM in a transverse plane, while weight bearing on the left leg in a hip position of L AF IR. (Figure 20) To summarize, management of R SIJP associated with a L AIC pattern includes a focus on R GM activation in a transverse plane with desired hip positions (R AF ER and L AF IR) that oppose the positions commonly seen in the L AIC pattern, and right adductor inhibition/lengthening as needed.

Conservative Management for Patients with Sacroiliac Joint Dysfunction 321

Fig. 20. Single Leg Wall Left AF IR with Right Glute Max

You should feel your left outer hip engage.

control and balance of your trunk.

8. Relax and repeat 4 more times.

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knee.

outside hip.

your mouth.

1. Place a band around both your legs slightly above your knees.

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2. Stand facing away from a door. Place your right foot flat against the door by bending your right

4. Shift your right knee down towards the floor. Your right knee will be below the level of your left.

5. While standing on your left leg, push your right foot firmly into the door as you maintain steady

6. Turn your right knee outward. You should feel your right outside hip engage along with your left

7. Balance in this position while you take 4-5 deep breaths in through your nose and out through

3. Align your knees together by adjusting your body's position and distance from the door.

Fig. 19. Supine Hooklying Adductor Magnus Inhibition


Fig. 19. Supine Hooklying Adductor Magnus Inhibition

2. Place a bolster or pillow of appropriate size on your right side.

You should feel a stretch across your right inner thigh.

7. Keeping both legs together, slowly bring them upright as one unit.

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tailbone is raised slightly off the mat. Keep your back flat on the mat.

3. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your

4. Maintaining a pelvic tilt, let your right knee lower to the side until it reaches the bolster or pillows.

5. Hold this position while you take 4-5 deep breaths in through your nose and out through your

1. Lie on your back with your feet on a 2-inch block.

6. Let your left knee drop down to meet your right.

8. Relax and repeat 4 more times.

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mouth.

Fig. 20. Single Leg Wall Left AF IR with Right Glute Max


Conservative Management for Patients with Sacroiliac Joint Dysfunction 323

1. Lie on your right side with your toes on a wall, ankles and knees together and your back rounded.

2. Place a bolster of appropriate size between your feet and a towel between your knees. Your left

3. Place tubing around your left leg just below your knee for resistance. Have another person hold

9. Continue the sequence until you have completed 4-5 breaths in and out. Attempt to pull back your

6. Exhale through your mouth as you squeeze your left knee down into the towel for 3 seconds. 7. Inhale again as you "pull back" your left leg further. You should begin to feel your left inner thigh

10. Relax your knees back to the starting position and repeat the sequence 4 more times.

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Fig. 21. Right Sidelying Left Adductor Pull Back

the other end to provide resistance. 4. Push your bottom foot into wall.

8. Exhale and squeeze your left knee down.

left leg further each time you inhale.

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engage.

knee should be lower than your left hip and ankle.

Place a pillow under your head and keep back and neck relaxed.

5. Begin by inhaling slowly through your nose as you "pull back" your left leg.

#### **5.2 Left sacroiliac joint pain/dysfunction related to a left anterior interior chain pattern**

Clinical reasoning for L SIJP/SIJD related to a L AIC pattern is similar to that of the R SIJ but rather than the strongest focus being on the R GM, the focus is on addressing the left hip/femur ER that is thought to occur as a result of compensation for the asymmetrical pelvic position. Left hip IR may be a challenging position for a patient to achieve if they have over active/strong and perhaps short left hip external rotator muscles holding them into hip ER and strong/over active right adductors holding them in right IR or a position of COG shifted right. Patients however require left hip IR for early stance phase of gait which requires them to shift their left acetabulum over the left femoral head. Compensation for the inability to get L AF IR may result in too much motion occurring in the L SIJ which may contribute to L SIJ instability. Intervention then would focus on training the left hip to IR via motion of the left acetabulum to move over the left femur (AF IR) and to activate left hip IR muscle such as the anterior gluteus medius (ant glut med) and the ischiocondylar (IC) portion of the left adductor magnus (AM). There are no known published articles relating to management of patients with SIJP that describe exercises or the importance of exercises that activate the adductors or anterior gluteus medius with the exception of one published case study that used Postural Restoration exercises.47 Additionally, there is one poster presented and abstract published including a case series of patients with SIJP where Postural Restoration exercises were prescribed.69, 70

If the pattern has been present for a long time, the L posterior capsule/ischiofemoral ligament may become adaptively short. This would require stretching/lengthening of the posterior hip ligament to allow for the L AF IR position and proper seating of the left femoral head into the acetabulum. An exercise called the Right Sidelying Left Adductor Pull Back48 done in right sidelying facilitates the desired hip positions (L AF IR and concomitant R AF ER), stretches the left ischiofemoral ligament/posterior capsule and activates left hip IR muscle i.e. adductors. (Figure 21) Resistance can be used to facilitate recruitment of the left hamstrings/adductors if desired, however that requires an individual to hold the band and may not be feasible for many patients.

A Left Sidelying Knee to Knee exercise46-48 takes advantage of gravity when activating left hip IR muscles (adductor magnus and anterior glut med) while also activating the R GM in a transverse plane to anchor the left hemipelvis back to the L and discourages over activity of paraspinals and an excessive lordotic position. (Figure 22) Another exercise to activate the left anterior gluteus medius against resistance while having the hip internally rotate (femur on acetabulum or "FA IR") is the Supine Hooklying Right Glute Max with Left Glute Med. (Figure 23) The Left Sidelying Left Flexed Adduction with concomitant Right Lowered Extended Abduction71 exercise integrates L abdominal wall activation along with L hip IR muscle (ant glut med and IC AM) with right GM and glut med in a position of right hip and knee extension as used in a R stance phase of gait. (Figure 24) This exercise may help to neuromuscularly reeducate the patient's left leg to rotate internally rather than externally while in a right stance phase of gait. Lastly, an exercise designed to activate the left internal oblique and transverse abdominus while also activating the right GM and L IC AM in a position of left stance phase of gait is the Left Sidelying IO/TA and Left Adductor with Right Glute Max. (Figure 25) This exercise may help to neuromuscularly reeducate the patient's left leg to rotate internally rather than externally while in a left stance phase of gait, while keeping the COG shifted left and the abdominal wall muscles on.

**5.2 Left sacroiliac joint pain/dysfunction related to a left anterior interior chain pattern**  Clinical reasoning for L SIJP/SIJD related to a L AIC pattern is similar to that of the R SIJ but rather than the strongest focus being on the R GM, the focus is on addressing the left hip/femur ER that is thought to occur as a result of compensation for the asymmetrical pelvic position. Left hip IR may be a challenging position for a patient to achieve if they have over active/strong and perhaps short left hip external rotator muscles holding them into hip ER and strong/over active right adductors holding them in right IR or a position of COG shifted right. Patients however require left hip IR for early stance phase of gait which requires them to shift their left acetabulum over the left femoral head. Compensation for the inability to get L AF IR may result in too much motion occurring in the L SIJ which may contribute to L SIJ instability. Intervention then would focus on training the left hip to IR via motion of the left acetabulum to move over the left femur (AF IR) and to activate left hip IR muscle such as the anterior gluteus medius (ant glut med) and the ischiocondylar (IC) portion of the left adductor magnus (AM). There are no known published articles relating to management of patients with SIJP that describe exercises or the importance of exercises that activate the adductors or anterior gluteus medius with the exception of one published case study that used Postural Restoration exercises.47 Additionally, there is one poster presented and abstract published including a case series of patients with SIJP where Postural

If the pattern has been present for a long time, the L posterior capsule/ischiofemoral ligament may become adaptively short. This would require stretching/lengthening of the posterior hip ligament to allow for the L AF IR position and proper seating of the left femoral head into the acetabulum. An exercise called the Right Sidelying Left Adductor Pull Back48 done in right sidelying facilitates the desired hip positions (L AF IR and concomitant R AF ER), stretches the left ischiofemoral ligament/posterior capsule and activates left hip IR muscle i.e. adductors. (Figure 21) Resistance can be used to facilitate recruitment of the left hamstrings/adductors if desired, however that requires an individual to hold the band

A Left Sidelying Knee to Knee exercise46-48 takes advantage of gravity when activating left hip IR muscles (adductor magnus and anterior glut med) while also activating the R GM in a transverse plane to anchor the left hemipelvis back to the L and discourages over activity of paraspinals and an excessive lordotic position. (Figure 22) Another exercise to activate the left anterior gluteus medius against resistance while having the hip internally rotate (femur on acetabulum or "FA IR") is the Supine Hooklying Right Glute Max with Left Glute Med. (Figure 23) The Left Sidelying Left Flexed Adduction with concomitant Right Lowered Extended Abduction71 exercise integrates L abdominal wall activation along with L hip IR muscle (ant glut med and IC AM) with right GM and glut med in a position of right hip and knee extension as used in a R stance phase of gait. (Figure 24) This exercise may help to neuromuscularly reeducate the patient's left leg to rotate internally rather than externally while in a right stance phase of gait. Lastly, an exercise designed to activate the left internal oblique and transverse abdominus while also activating the right GM and L IC AM in a position of left stance phase of gait is the Left Sidelying IO/TA and Left Adductor with Right Glute Max. (Figure 25) This exercise may help to neuromuscularly reeducate the patient's left leg to rotate internally rather than externally while in a left stance phase of gait,

while keeping the COG shifted left and the abdominal wall muscles on.

Restoration exercises were prescribed.69, 70

and may not be feasible for many patients.

#### Fig. 21. Right Sidelying Left Adductor Pull Back



Conservative Management for Patients with Sacroiliac Joint Dysfunction 325

Fig. 23. Supine Hooklying Right Glute Max with Left Glute Med

left. You should feel your right inner thigh engage.

Copyright © Postural Restoration Institute™ used with permission,

outside hip engage.

through your mouth. 8. Relax and repeat 4 more times.

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your left outer hip engage.

1. Lie on your back with your feet on a 2-inch block and your knees bent. 2. Place a ball between your knees and a band around your ankles.

3. Inhale through your nose and then exhale through your mouth performing a pelvic tilt so that your tailbone is raised slightly off the mat. Keep your back flat on the mat. 4. Shift your right knee down towards you so that your right knee is slightly below your

5. Now lift your left foot off of the block. You should feel the back of your right leg and

6. With your left foot off of the block turn your left ankle out to the side. You should feel

7. Hold this position while you take 4-5 deep breaths in through your nose and out

#### Fig. 22. Left Sidelying Knee to Knee


Fig. 22. Left Sidelying Knee to Knee

your mouth.

7. Relax and repeat 4 more times.

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2. Place a bolster underneath your ankles. 3. Push your bottom toes into the wall. 4. Lift up or turn "out" your upper thigh.

1. Lie on your left side with your toes on the wall, knees together and back rounded.

Copyright © Postural Restoration Institute™ used with permission,

5. Then lift up or turn "in" your lower thigh. You should feel your left inner thigh engage.

6. Hold your legs together while you take 4-5 deep breaths in through your nose and out through

Fig. 23. Supine Hooklying Right Glute Max with Left Glute Med


Conservative Management for Patients with Sacroiliac Joint Dysfunction 327

2. Place a 2-3 inch towel under your left side and 1-2 pillows under your head so that your neck is

4. Place your right foot slightly ahead of your left knee and drop the inside of your right foot toward

5. Push your left hip down into the mat, bring your right knee forward and arch your left abdominal wall over the bolster. With your right hand you should feel your left abdominal wall engage. Do

6. Keeping your right arch in contact with the mat, turn your right knee out. You should feel your

7. Keeping your left hip down and right knee turned out, turn your left toes up towards the ceiling

8. Hold this position while you take 4-5 deep breaths in through your nose and out through your

the mat so that you can feel the arch of your foot push into your shoe.

and pick your entire leg up. You should feel your left inner thigh engage.

Fig. 25. Left Sidelying IO/TA and Left Adductor with Right Glute Max Copyright © Postural Restoration Institute™ used with permission

1. Lie on your left side with your left leg straight.

3. Bend your right leg and cross it over your left leg.

slightly side bent to the right.

not engage your neck.

mouth.

right outside hip engage.

9. Relax and repeat 4 more times.

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#### Fig. 24. Left Sidelying Left Flexed Adduction with Concomitant Right Lowered Extended Abduction


Fig. 24. Left Sidelying Left Flexed Adduction with Concomitant Right Lowered Extended

under your head so that your neck is slightly side bent to the right.

of the bolster. You should feel your right outer hip engage.

Copyright © Postural Restoration Institute™ used with permission

1. Lie on your left side and place a 2-3 inch bolster under your left abdominal wall and 1-2 pillows

2. Place a bolster of appropriate size under your right ankle so that your right leg is level with your

3. Inhale through your nose and as you exhale through your mouth reach down with your right foot. 4. Push your left hip down firmly into the mat and try to arch your left abdominal wall. You should

5. With your left abdominal wall engaged and your right leg reaching down, push the outside border of your left foot down into the mat and "turn" your left knee up. You should feel your left inner

6. With your left inner thigh engaged, turn your right toes out and attempt to pick your right leg off

7. Hold this position while you take 4-5 deep breaths in through your nose and out through your

Abduction

trunk and bend your left knee.

8. Relax and repeat 4 more times.

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thigh engage.

mouth.

feel your left abdominal wall engage.


Fig. 25. Left Sidelying IO/TA and Left Adductor with Right Glute Max Copyright © Postural Restoration Institute™ used with permission www.posturalrestoration.com

Conservative Management for Patients with Sacroiliac Joint Dysfunction 329

used to manage patients with SIJP/SIJD and to compare interventions to determine which

[1] Paris SV. Introduction to spinal evaluation and manipulation. 3rd ed. St. Augustine:

[2] Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis and

[3] Schwarzer AC CNA, N Bogduk. The Sacroiliac Joint in Chronic Low Back Pain. Spine

[4] Maignes JY, Aivaliklis A, Pfefer F. Results of Sacroiliac Joint Double Block and Value of

[5] Ostgaard HC, Andersson GBJ, Karlsson K. Prevalence of back pain inpregnancy. Spine

[6] van Kessel-Cobelens AM, Verhagen AP, Mens JM, Snijders CJ, Koes BW. Pregnancy-

mobility of the sacroiliac joints. J Manipulative Phys Ther 2008;31(2):130-6. [7] van der Wurff P, Hagmeijer RHM, Meyne W. Clinical tests of the sacroiliac joint: a

[8] Szadek KM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. .

[9] Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with

[10] Fortin JD, Falco FJ. The Fortin finger test: an indicator of sacroiliac pain. Am J Orthop

[11] Fortin JD, Dwyer AP, West S. SIJ: pain referral maps upon applying a new

[12] O-Sullivan PB. Altered Motor Control strategies in Subjects With Sacroiliac Joint Pain

[13] Lee D. The Pelvic Girdle an approach to the examinat in and treatment of the lumbopelvic-hip region. 3rd ed. New York, NY: Churchhill Livingstone, 2004. [14] Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joint: a

[15] Stuber KJ. Specificity, sensitivity and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc 2007;51:30-41.

[17] Freburger JK RD. Using Published Evidence to Guide the Examination of the Sacroiliac

[18] Maignes JY AA, Pfefer F. Results of Sacroiliac Joint Double Block and Value of

[19] Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and

During the Active Straight-Leg-Raise Test. Spine 2002;27(1):E1-E8.

[16] Sizer PS, Phelps V, Thompsen K. Disorders of the sacroiliac joint. 2 2002;1:17-34.

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30-6.

**7. References** 

#### **6. Published case studies involving Postural Restoration for L AIC patterns**

A recent case study was published describing PR management for a 65 year old female with L SIJP/SIJD, and painful intercourse.47 Left hamstrings were activated to restore optimal sagittal plane pelvic position because of the anterior tilt of the left innominate. L AF IR position was achieved and left IR muscle was activated (anterior glut med and L IC AM). R GM was activated to help train the patient to keep her L acetabulum over her L femur (L AF IR). She had a remarkable decrease in her pain from an 8/10 to a 0/10 and an increase in her function as measured by a change from an Oswestry Disability Index (ODI) score of 20% to 0%.47 A case series was presented at an international meeting on four patients with SIJP.69 There were two patients with right SIJP and two with left SIJP from 30-54 years of age. They had duration of pain from two weeks to three years, and were seen between two to seven visits over 2.5 to 3.5 weeks. The improvement in function based on the ODI change score ranged between 16-33%, with a mean of 26% and an average percent improvement in function of 85%. The Patient Specific Functional Scale (PSFS) was also used to measure function and the change scores ranged from 3.0-7.3 and a mean of 5.2.72 Both the ODI and PSFS exceeded the minimally clinical important difference (MCID) of 10 for the ODI and 2 for the PSFS.72, 73 Currently a RCT is underway to investigate outcomes related to pain and function comparing traditional intervention to postural restoration exercises for patients with sacroiliac joint pain. This data however is not yet published. There are four other case studies relating to a L AIC pattern where a Postural Restoration approach was used however these were not specifically for patients with SIJP, but rather LBP,46 Thoracic Outlet Syndrome,44 Asthma51 and Trochanteric Bursitis.50

In summary, disorders involving the SIJs are relatively common and can be diagnosed using subjective history elements (pain arising from long term sitting, pain located over one SIJ (Fortin's Finger Test) and possibly into the buttock (Fortin's Area) and special tests for load transfer (ASLR) and pain provocation (e.g. posterior shear, compression). Motion palpation tests should be avoided as their reliability is poor. The Ober's Test or Adduction Drop Test may be helpful in determining the presence of pelvic asymmetry and/or ipsilateral hip flexor tone and/or adductor tone. There is motion in the SIJs, and asymmetrical laxity is associated with PGP rather than generalized bilateral SIJ laxity. Motion in the sagittal plane is greater in the R SIJ than the L SIJ. The concepts of form and form closure are important to integrate into clinical reasoning for patients with SIJP/SIJD. Force closure may be reduced *or excessive* in patients with SIJP/SIJD. There is a paucity of research, particularly higher levels of research to substantiate interventions for these conditions. Many lower levels of research i.e. case reports and descriptive studies do not describe the exercises used in enough detail to apply them to patient management or to replicate the studies. This chapter offered a theoretical framework and biomechanical rationale for the management of patients with right and/or left SIJP as it relates to an underlying postural pattern of asymmetry referred to as a Left Anterior Interior Chain (L AIC) pattern. Unique Postural Restoration therapeutic exercises with face validity to address the theoretical framework were also presented and described. These exercises focused on right gluteus maximus activation in the transverse plane for right SIJP/SIJD and on left anterior gluteus medius and ischiocondylar adductor magnus activation for left SIJP/SIJD. Peer reviewed and published data to highlight a theoretical framework for therapeutic exercise management of SIJP is currently lacking. Randomized controlled trials are needed to substantiate the effectiveness of all interventions used to manage patients with SIJP/SIJD and to compare interventions to determine which are most efficacious.

#### **7. References**

328 Low Back Pain

**6. Published case studies involving Postural Restoration for L AIC patterns**  A recent case study was published describing PR management for a 65 year old female with L SIJP/SIJD, and painful intercourse.47 Left hamstrings were activated to restore optimal sagittal plane pelvic position because of the anterior tilt of the left innominate. L AF IR position was achieved and left IR muscle was activated (anterior glut med and L IC AM). R GM was activated to help train the patient to keep her L acetabulum over her L femur (L AF IR). She had a remarkable decrease in her pain from an 8/10 to a 0/10 and an increase in her function as measured by a change from an Oswestry Disability Index (ODI) score of 20% to 0%.47 A case series was presented at an international meeting on four patients with SIJP.69 There were two patients with right SIJP and two with left SIJP from 30-54 years of age. They had duration of pain from two weeks to three years, and were seen between two to seven visits over 2.5 to 3.5 weeks. The improvement in function based on the ODI change score ranged between 16-33%, with a mean of 26% and an average percent improvement in function of 85%. The Patient Specific Functional Scale (PSFS) was also used to measure function and the change scores ranged from 3.0-7.3 and a mean of 5.2.72 Both the ODI and PSFS exceeded the minimally clinical important difference (MCID) of 10 for the ODI and 2 for the PSFS.72, 73 Currently a RCT is underway to investigate outcomes related to pain and function comparing traditional intervention to postural restoration exercises for patients with sacroiliac joint pain. This data however is not yet published. There are four other case studies relating to a L AIC pattern where a Postural Restoration approach was used however these were not specifically for patients with SIJP, but rather LBP,46 Thoracic Outlet

In summary, disorders involving the SIJs are relatively common and can be diagnosed using subjective history elements (pain arising from long term sitting, pain located over one SIJ (Fortin's Finger Test) and possibly into the buttock (Fortin's Area) and special tests for load transfer (ASLR) and pain provocation (e.g. posterior shear, compression). Motion palpation tests should be avoided as their reliability is poor. The Ober's Test or Adduction Drop Test may be helpful in determining the presence of pelvic asymmetry and/or ipsilateral hip flexor tone and/or adductor tone. There is motion in the SIJs, and asymmetrical laxity is associated with PGP rather than generalized bilateral SIJ laxity. Motion in the sagittal plane is greater in the R SIJ than the L SIJ. The concepts of form and form closure are important to integrate into clinical reasoning for patients with SIJP/SIJD. Force closure may be reduced *or excessive* in patients with SIJP/SIJD. There is a paucity of research, particularly higher levels of research to substantiate interventions for these conditions. Many lower levels of research i.e. case reports and descriptive studies do not describe the exercises used in enough detail to apply them to patient management or to replicate the studies. This chapter offered a theoretical framework and biomechanical rationale for the management of patients with right and/or left SIJP as it relates to an underlying postural pattern of asymmetry referred to as a Left Anterior Interior Chain (L AIC) pattern. Unique Postural Restoration therapeutic exercises with face validity to address the theoretical framework were also presented and described. These exercises focused on right gluteus maximus activation in the transverse plane for right SIJP/SIJD and on left anterior gluteus medius and ischiocondylar adductor magnus activation for left SIJP/SIJD. Peer reviewed and published data to highlight a theoretical framework for therapeutic exercise management of SIJP is currently lacking. Randomized controlled trials are needed to substantiate the effectiveness of all interventions

Syndrome,44 Asthma51 and Trochanteric Bursitis.50


Conservative Management for Patients with Sacroiliac Joint Dysfunction 331

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**1. Introduction** 

suggestions for future avenues of research.

**2. Chronic low back pain** 

**14** 

*USA* 

**Yoga as a Treatment for Low** 

*1VA San Diego Healthcare System, 2University of California San Diego,*

**Back Pain: A Review of the Literature** 

Chronic low back pain (CLBP) affects millions of people worldwide. In addition to chronic pain, CLBP is associated with increased disability and psychological symptoms, and reduced health-related quality of life (HRQOL). There are many treatment options for chronic low back pain, although no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as an additional approach for treating CLBP. The objective of this chapter is to provide an introduction to yoga as a treatment for CLBP before reviewing the published literature to date supporting the efficacy of yoga for CLBP. Two large randomized controlled trials (RCTs) published late in 2011 provide the most conclusive evidence to date in this area. With few exceptions, previous studies and the recent RCTs indicate that yoga can reduce pain and disability, can be practiced safely, and is well received by participants. Some studies also indicate that yoga can reduce pain medication use and improve psychological symptoms, but these effects are currently not as well established. We summarize these results, discuss their implications, and examine caveats and limitations of the current research evidence. Finally, we provide

Back pain is the second most common reason for physician visits and approximately 25% of the US population report having had back pain that lasted all day in the prior 3 months. (Deyo, Mirza, & Martin, 2006) It is estimated that 90% of all acute back pain episodes resolve within 4 weeks, (Anderson, 1997) up to a third of those who sought treatment for their back pain reported persistent pain one year later, (Von Korff & Saunders, 1996) with 20% also reporting limitations of activity. It was estimated that back pain-related health care costs were about \$26 billion in 1998 and that the health care costs of back pain patients are 60%

Low back pain is the most common type of back pain and is a prevalent condition that afflicts about 70% of people in developing countries at some point in their lifetime. (Anderson, 1997) The incidence of low back pain is greatest in persons of young adult and

higher than those without back pain. (Luo, Pietrobon, Sun, Liu, & Hey, 2004)

Erik J. Groessl1,2, Marisa Sklar3 and Douglas Chang1,2

*3SDSU/UCSD Joint Doctoral Program in Clinical Psychology,* 


### **Yoga as a Treatment for Low Back Pain: A Review of the Literature**

Erik J. Groessl1,2, Marisa Sklar3 and Douglas Chang1,2 *1VA San Diego Healthcare System, 2University of California San Diego, 3SDSU/UCSD Joint Doctoral Program in Clinical Psychology, USA* 

#### **1. Introduction**

332 Low Back Pain

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Chronic low back pain (CLBP) affects millions of people worldwide. In addition to chronic pain, CLBP is associated with increased disability and psychological symptoms, and reduced health-related quality of life (HRQOL). There are many treatment options for chronic low back pain, although no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as an additional approach for treating CLBP. The objective of this chapter is to provide an introduction to yoga as a treatment for CLBP before reviewing the published literature to date supporting the efficacy of yoga for CLBP. Two large randomized controlled trials (RCTs) published late in 2011 provide the most conclusive evidence to date in this area. With few exceptions, previous studies and the recent RCTs indicate that yoga can reduce pain and disability, can be practiced safely, and is well received by participants. Some studies also indicate that yoga can reduce pain medication use and improve psychological symptoms, but these effects are currently not as well established. We summarize these results, discuss their implications, and examine caveats and limitations of the current research evidence. Finally, we provide suggestions for future avenues of research.

#### **2. Chronic low back pain**

Back pain is the second most common reason for physician visits and approximately 25% of the US population report having had back pain that lasted all day in the prior 3 months. (Deyo, Mirza, & Martin, 2006) It is estimated that 90% of all acute back pain episodes resolve within 4 weeks, (Anderson, 1997) up to a third of those who sought treatment for their back pain reported persistent pain one year later, (Von Korff & Saunders, 1996) with 20% also reporting limitations of activity. It was estimated that back pain-related health care costs were about \$26 billion in 1998 and that the health care costs of back pain patients are 60% higher than those without back pain. (Luo, Pietrobon, Sun, Liu, & Hey, 2004)

Low back pain is the most common type of back pain and is a prevalent condition that afflicts about 70% of people in developing countries at some point in their lifetime. (Anderson, 1997) The incidence of low back pain is greatest in persons of young adult and

Yoga as a Treatment for Low Back Pain: A Review of the Literature 335

al., 2007) Patients that do not improve after treatment with self-care activities and/or medications are good candidates for non-pharmacological treatments. Non-pharmacological treatments include physical treatments (i.e. heat, ice, ultrasound, massage therapy), spinal manipulation, and forms of injection therapy. (Chou & Huffman, 2007b) Other studies have examined interventions such as exercise therapy, yoga, back schools, acupuncture, psychological therapies, laser treatment, lumbar supports, traction, and transcutaneous

Non-pharmacological treatments are diverse, and vary considerably in the quality and amount of evidence supporting them and in the effect sizes they produce 14. Despite varying evidence of their effectiveness, non-pharmacologic treatment options are widely recommended, especially by primary care physicians when their patients have not improved. (Di Iorio, Henley, & Doughty, 2000; Freburger, Carey, & Holmes, 2005) Ratings of the level of evidence for non-pharmacological treatments in recent guidelines are as follows: "good" scientific evidence was available for spinal manipulation (moderate effects), multidisciplinary approaches (moderate effects), exercise (small to moderate effects), and some psychological interventions (moderate effects), exercise (small to moderate effects), and some psychological interventions (moderate effects); (Chou & Huffman, 2007b) a "fair" level of evidence was found for yoga (moderate effects), acupuncture (moderate effects), functional restoration (moderate effects), back schools (small effects), and continuous traction (not effective); and finally, effects were not rated for the seven other therapies for which evidence was judged as "Poor". Overall, the recommendations suggest that several non-pharmacological treatments are moderately effective, but none stand out as exceptionally beneficial. Thus, the characteristics, preferences and resources of individual patients, the cost and risk of the interventions, and consideration of the disease's natural history itself become important factors in treatment decision-making for chronic low back pain. For instance, some patients are at greater risk for developing addictions when treated with narcotic pain

medications, making non-pharmacological treatments a more appealing choice.

Injectional therapy to treat back conditions has become increasingly popular. Some injections (e.g. trigger point injections, acupuncture, prolotherapy) can be considered one of the many sundry non-pharmacological treatments. Other injections (e.g. epidural steroid injections, facet injections, medial branch blocks, radiofrequency ablation) are performed more frequently for spinal conditions and deserve specific discussion. The utilization rates for injectional therapies has risen about 250% between 1994 and 2001. (Chou, Atlas, Stanos, & Rosenquist, 2009) However, the evidence for these therapies is controversial. There are few well designed studies that support their usage and many studies with limitations that

The best evidence supports the use of epidural steroid injections in the treatment of radicular pain. Bush et al. (Bush, Cowan, Katz, & Gishen, 1992) followed 165 patients with lumbar radicular pain for one year. The patients were given ~3 lumbar epidural steroid injections (using a caudal approach). 14% of the patients opted for surgical decompression, the rest had a satisfactory clinical recovery, with 94% reduction in visual analog scale pain and partial to complete resolution of disk herniations and disk bulges. Riew et al. followed

electrical nerve stimulation.

**Medical procedures** 

show either benefit or no benefit.

**Non-pharmacological treatments** 

middle age, with 74% of all health visits for low back pain made by persons between the ages of 18 and 64 years. (AAOS, 2008) Additionally, in this group, low back pain is often associated by reduced ability to work or inability to work at all. The total economic impact (health care costs plus socioeconomic costs) has therefore been estimated at over \$100 billion each year. (AAOS, 2008) In the past, chronic low back pain was defined as low back pain lasting 12 weeks or more, but current guidelines now primarily differentiate between acute low back pain lasting less than 4 weeks and chronic, subacute low back pain lasting greater than 4 weeks. (Chou et al., 2007) This distinction coincides with the data cited above showing most back pain resolves on its own within 4 weeks.

Chronic low back pain results in more than just pain and discomfort. Persons with chronic low back pain also experience a variety of other symptoms and functional limitations. These include increased psychological symptoms such as depression, (Currie & Wang, 2004; Sullivan, Reesor, Mikail, & Fisher, 1992) anxiety, (Manchikanti, Pampati, Beyer, Damron, & Barnhill, 2002; Thompson, Bower, & Tyrer, 2007) increased disability, (Guo, Tanaka, Halperin, & Cameron, 1999) and reduced health-related quality of life (HRQOL). (Burstrom, Johannesson, & Diderichsen, 2001; Kosinski et al., 2005) Low back pain has a major impact on workforce productivity, with millions of workdays (Guo et al., 1999) (costing billions of dollars) lost for employees with back pain each year in the US. Research on disability and lost productivity among people with low back pain indicates that psychological factors are independently associated with lost productivity, increased disability, (Schiphorst Preuper et al., 2007) and increased healthcare utilization. (Keeley et al., 2008) Using formal diagnostic criteria, results of a 2004 research study found that 20% of persons with chronic back pain had major depression while only 6% of pain-free individuals were classified this way. (Currie & Wang, 2004) Higher rates of depression among individuals with low back pain have been found previously in many other studies, (Manchikanti et al., 2002; Sullivan et al., 1992) along with elevated rates of other disorders such as anxiety and somatoform disorder. (Manchikanti et al., 2002) Although the causal relationship between psychological symptoms and CLBP is complex, research evidence indicates that psychological symptoms often improve in low back pain patients after exercise interventions, even if the interventions were not specifically designed to affect the psychological symptoms. (Roche et al., 2007) Conversely, placebo or sham treatments for low back pain have not resulted in significant changes in psychological symptoms. (Thompson et al., 2007)

#### **Current treatments for chronic low back pain**

Treatment recommendations for low back pain have been updated in 2007 and begin with an effort to categorize patients into three groups: Nonspecific low back pain, low back pain with radiating leg pain, and low back pain from a specific cause (e.g. fracture, malignancy, infection, cauda equine syndrome, or ankylosing spondylitis). (Chou et al., 2007) The majority of chronic low back pain cases (85%) are nonspecific and are not linked to specific physical abnormalities. (van Tulder, Assendelft, Koes, & Bouter, 1997) When a treating physician deems low back pain to be non-specific, health care providers are strongly recommended to begin treatment by providing patients with evidence-based information and to also encourage them to stay active and perform self-care activities. Self-care or selfmanagement activities are strongly recommended because they are inexpensive and are almost as effective as other non-pharmacological options. Another front-line option for patients with nonspecific chronic back pain is medication. (Chou & Huffman, 2007a; Chou et al., 2007) Patients that do not improve after treatment with self-care activities and/or medications are good candidates for non-pharmacological treatments. Non-pharmacological treatments include physical treatments (i.e. heat, ice, ultrasound, massage therapy), spinal manipulation, and forms of injection therapy. (Chou & Huffman, 2007b) Other studies have examined interventions such as exercise therapy, yoga, back schools, acupuncture, psychological therapies, laser treatment, lumbar supports, traction, and transcutaneous electrical nerve stimulation.

#### **Non-pharmacological treatments**

334 Low Back Pain

middle age, with 74% of all health visits for low back pain made by persons between the ages of 18 and 64 years. (AAOS, 2008) Additionally, in this group, low back pain is often associated by reduced ability to work or inability to work at all. The total economic impact (health care costs plus socioeconomic costs) has therefore been estimated at over \$100 billion each year. (AAOS, 2008) In the past, chronic low back pain was defined as low back pain lasting 12 weeks or more, but current guidelines now primarily differentiate between acute low back pain lasting less than 4 weeks and chronic, subacute low back pain lasting greater than 4 weeks. (Chou et al., 2007) This distinction coincides with the data cited above

Chronic low back pain results in more than just pain and discomfort. Persons with chronic low back pain also experience a variety of other symptoms and functional limitations. These include increased psychological symptoms such as depression, (Currie & Wang, 2004; Sullivan, Reesor, Mikail, & Fisher, 1992) anxiety, (Manchikanti, Pampati, Beyer, Damron, & Barnhill, 2002; Thompson, Bower, & Tyrer, 2007) increased disability, (Guo, Tanaka, Halperin, & Cameron, 1999) and reduced health-related quality of life (HRQOL). (Burstrom, Johannesson, & Diderichsen, 2001; Kosinski et al., 2005) Low back pain has a major impact on workforce productivity, with millions of workdays (Guo et al., 1999) (costing billions of dollars) lost for employees with back pain each year in the US. Research on disability and lost productivity among people with low back pain indicates that psychological factors are independently associated with lost productivity, increased disability, (Schiphorst Preuper et al., 2007) and increased healthcare utilization. (Keeley et al., 2008) Using formal diagnostic criteria, results of a 2004 research study found that 20% of persons with chronic back pain had major depression while only 6% of pain-free individuals were classified this way. (Currie & Wang, 2004) Higher rates of depression among individuals with low back pain have been found previously in many other studies, (Manchikanti et al., 2002; Sullivan et al., 1992) along with elevated rates of other disorders such as anxiety and somatoform disorder. (Manchikanti et al., 2002) Although the causal relationship between psychological symptoms and CLBP is complex, research evidence indicates that psychological symptoms often improve in low back pain patients after exercise interventions, even if the interventions were not specifically designed to affect the psychological symptoms. (Roche et al., 2007) Conversely, placebo or sham treatments for low back pain have not resulted in

showing most back pain resolves on its own within 4 weeks.

significant changes in psychological symptoms. (Thompson et al., 2007)

Treatment recommendations for low back pain have been updated in 2007 and begin with an effort to categorize patients into three groups: Nonspecific low back pain, low back pain with radiating leg pain, and low back pain from a specific cause (e.g. fracture, malignancy, infection, cauda equine syndrome, or ankylosing spondylitis). (Chou et al., 2007) The majority of chronic low back pain cases (85%) are nonspecific and are not linked to specific physical abnormalities. (van Tulder, Assendelft, Koes, & Bouter, 1997) When a treating physician deems low back pain to be non-specific, health care providers are strongly recommended to begin treatment by providing patients with evidence-based information and to also encourage them to stay active and perform self-care activities. Self-care or selfmanagement activities are strongly recommended because they are inexpensive and are almost as effective as other non-pharmacological options. Another front-line option for patients with nonspecific chronic back pain is medication. (Chou & Huffman, 2007a; Chou et

**Current treatments for chronic low back pain** 

Non-pharmacological treatments are diverse, and vary considerably in the quality and amount of evidence supporting them and in the effect sizes they produce 14. Despite varying evidence of their effectiveness, non-pharmacologic treatment options are widely recommended, especially by primary care physicians when their patients have not improved. (Di Iorio, Henley, & Doughty, 2000; Freburger, Carey, & Holmes, 2005) Ratings of the level of evidence for non-pharmacological treatments in recent guidelines are as follows: "good" scientific evidence was available for spinal manipulation (moderate effects), multidisciplinary approaches (moderate effects), exercise (small to moderate effects), and some psychological interventions (moderate effects), exercise (small to moderate effects), and some psychological interventions (moderate effects); (Chou & Huffman, 2007b) a "fair" level of evidence was found for yoga (moderate effects), acupuncture (moderate effects), functional restoration (moderate effects), back schools (small effects), and continuous traction (not effective); and finally, effects were not rated for the seven other therapies for which evidence was judged as "Poor". Overall, the recommendations suggest that several non-pharmacological treatments are moderately effective, but none stand out as exceptionally beneficial. Thus, the characteristics, preferences and resources of individual patients, the cost and risk of the interventions, and consideration of the disease's natural history itself become important factors in treatment decision-making for chronic low back pain. For instance, some patients are at greater risk for developing addictions when treated with narcotic pain medications, making non-pharmacological treatments a more appealing choice.

#### **Medical procedures**

Injectional therapy to treat back conditions has become increasingly popular. Some injections (e.g. trigger point injections, acupuncture, prolotherapy) can be considered one of the many sundry non-pharmacological treatments. Other injections (e.g. epidural steroid injections, facet injections, medial branch blocks, radiofrequency ablation) are performed more frequently for spinal conditions and deserve specific discussion. The utilization rates for injectional therapies has risen about 250% between 1994 and 2001. (Chou, Atlas, Stanos, & Rosenquist, 2009) However, the evidence for these therapies is controversial. There are few well designed studies that support their usage and many studies with limitations that show either benefit or no benefit.

The best evidence supports the use of epidural steroid injections in the treatment of radicular pain. Bush et al. (Bush, Cowan, Katz, & Gishen, 1992) followed 165 patients with lumbar radicular pain for one year. The patients were given ~3 lumbar epidural steroid injections (using a caudal approach). 14% of the patients opted for surgical decompression, the rest had a satisfactory clinical recovery, with 94% reduction in visual analog scale pain and partial to complete resolution of disk herniations and disk bulges. Riew et al. followed

Yoga as a Treatment for Low Back Pain: A Review of the Literature 337

spent in each pose, the extent to which deep breathing is emphasized, level of emphasis on proper bodily alignment, room temperature, spiritual emphasis, meditation time, and the overall intensity and difficulty of the poses. Hundreds or possibly thousands of postures and variations have been developed over time, each one designed to stretch, strengthen, or engage specific areas of the body. When modified, Hatha yoga can be practiced by almost anyone, not just the healthy and flexible. This can be achieved by the use of props which enables people of all ages and ability levels (physical and mental) to perform poses that achieve benefit. (Iyengar, 1979) Yoga can be tailored to people with various physical or psychological limitations and can range from gentle to strenuous, with some types of yoga providing a cardiovascular workout, and others focused on relaxation and a calm mind. To be improve physical and mental health, the practice of yoga is usually performed at least once per week (twice is recommended), with increasing frequency of practice either at home or in a class, and gradual practice of more advanced postures as conditioning improves and

The popularity of yoga has grown tremendously in recent years. Data from the National Center for Complementary and Alternative Medicine (NCCAM) show that the usage of complementary and alternative medicine (CAM) treatments for all conditions is on the rise in the US. Back pain is the most common condition for which CAM treatments are sought. Yoga was the 5th most commonly used CAM treatment and its use increased significantly between 2002 and 2007. Yoga was used by 6.1% of all US adults and 2.1% of all children in

Although there are many studies claiming yoga can be an effective treatment for improving a wide variety of conditions (musculoskeletal problems, (Greendale, McDivit, Carpenter, Seeger, & Huang, 2002) cardiopulmonary function, (Raub, 2002) lipid and carbohydrate metabolism, (Bera & Rajapurkar, 1993) sleep problems, (Harinath et al., 2004) anxiety and depression, (Waelde, Thompson, & Gallagher-Thompson, 2004) ) study quality has been lacking, with a clear need for larger randomized, controlled trials (RCTs). (Luskin et al., 2000) The limitations of most previous yoga studies include being nonrandomized, a lack of validated outcome measures, a lack of data on dose response, and little examination of the underlying mechanisms. In addition, the yoga interventions being studied are often not well described. Yoga is multi-dimensional, so it is important to describe all of the components of each yoga intervention in order to compare across interventions and better understand which components are best for different disease populations. More recently, some larger, higher quality randomized studies have been conducted in areas including depression, (Sharma, Das, Mondal, Goswampi, & Gandhi, 2005) stress and anxiety, (Granath, Ingvarsson, von Thiele, & Lundberg, 2006; Smith, Hancock, Blake-Mortimer, & Eckert, 2007) HIV, (Brazier, Mulkins, & Verhoef, 2006) irritable bowel syndrome, (Kuttner et al., 2006) and chronic low back pain. (Sherman et al., 2011; Tilbrook et al., 2011) With very few exceptions, these more recent trials indicate that yoga has demonstrable beneficial effects, is rarely harmful, and is well received by participants with a wide variety of health problems. The psychological benefits of yoga are almost as well established as the physical benefits, as suggested by studies on stress,

strength increases. (Stiles, 2000)

**Broader effectiveness of yoga therapies** 

the use in 2007.

anxiety, and depression.

55 patients for five years with lumbar radicular pain who had initially opted for surgery. (Riew et al., 2006) The patients were offered lumbar epidural steroid injection therapy (using a transforaminal approach) prior to the planned surgery. After two years, 29 of the patients avoided surgery. After five years, 21 of the 29 patients were identified and re-evaluated. Four of the 21 patients had opted for surgical treatment, while 17 continued to avoid surgery. These 17 had significantly decreased neurological symptoms and pain.

Facet joint injections and medial branch blocks have been proposed to treat axial (nonradiating) low back pain. While there is good research to support their usage in cervical spine pain, the evidence to treat lumbar pain is more limited. (Chou et al., 2009) In one study, 95 patients were followed for 6 months following a beneficial response to anesthetic injections into the lumbar facet joints of subjects with back pain. (Carette et al., 1991) The patients were randomized for another treatment with cortisone versus saline. Variable treatment responses were observed. There was no additional benefit of steroid over saline after the initial anesthetic injection.

Lastly, surgical treatment of non-specific low back pain has not been shown to be reliably successful. (Zigler et al., 2007) Depending on the outcome measure or surgery utilized, "success" rates for surgery for low back pain only range from 40% - 65%.

#### **3. Yoga**

The word "yoga" means union, and refers to the goal of uniting individual human spirit or will with divine spirit or the True Self. (Bhaktivedanta Swami Prabhupada, 1997; Stiles, 2000) Classical yoga (Raja Yoga) is an ancient discipline that was first formally described by Patanjali around 200 BC in the Yoga Sutras. It has roots in Hindu religion and philosophy (Stiles, 2000) and was designed to create harmony of mind and body, and aid in achieving enlightenment or oneness with God. Although yoga has at times been misunderstood in the West as primarily "stretching", the postures or poses ('asanas'), comprise just one of eight components of a broader discipline of comprehensive physical, mental, and spiritual health and balance for individuals. However, many types of yoga do not include or do not emphasize stretching or postures, and are not considered Hatha yoga. (Sivananda, 1999; Yogananda, 1998) Modern Hatha yoga usually includes other classical yoga components such as breathing exercises ('pranayama'), concentration (pratyhara), and mindfulness/meditation (dhyana). (Iyengar, 1979) Thus, a typical Hatha yoga program consists of an instructor leading a group of students or practitioners through a series of yoga postures while performing deep breathing exercises for. Most classes last 60-90 minutes, and the instructor demonstrates the correct posture for practitioners, and provides verbal suggestions that encourage practitioners focus their attention or concentrate on deep breathing, postural alignment, on bodily sensations produced by the asanas. Depending on their training and often the class setting, instructors often encourage students to embrace positive cognitions or attitudes towards the world and themselves. This usually occurs at the beginning or end of the session and the instructors model these attitudes as well. Some yoga instructional centers provide a more complete social and spiritual community in which the additional components of classical yoga are also practiced.

There are many different types of Hatha yoga (Ashtanga, Anusara, Viniyoga, Bikram, etc). These styles or schools of Hatha yoga differ on variables such as pace, or the amount of time

55 patients for five years with lumbar radicular pain who had initially opted for surgery. (Riew et al., 2006) The patients were offered lumbar epidural steroid injection therapy (using a transforaminal approach) prior to the planned surgery. After two years, 29 of the patients avoided surgery. After five years, 21 of the 29 patients were identified and re-evaluated. Four of the 21 patients had opted for surgical treatment, while 17 continued to avoid

Facet joint injections and medial branch blocks have been proposed to treat axial (nonradiating) low back pain. While there is good research to support their usage in cervical spine pain, the evidence to treat lumbar pain is more limited. (Chou et al., 2009) In one study, 95 patients were followed for 6 months following a beneficial response to anesthetic injections into the lumbar facet joints of subjects with back pain. (Carette et al., 1991) The patients were randomized for another treatment with cortisone versus saline. Variable treatment responses were observed. There was no additional benefit of steroid over saline

Lastly, surgical treatment of non-specific low back pain has not been shown to be reliably successful. (Zigler et al., 2007) Depending on the outcome measure or surgery utilized,

The word "yoga" means union, and refers to the goal of uniting individual human spirit or will with divine spirit or the True Self. (Bhaktivedanta Swami Prabhupada, 1997; Stiles, 2000) Classical yoga (Raja Yoga) is an ancient discipline that was first formally described by Patanjali around 200 BC in the Yoga Sutras. It has roots in Hindu religion and philosophy (Stiles, 2000) and was designed to create harmony of mind and body, and aid in achieving enlightenment or oneness with God. Although yoga has at times been misunderstood in the West as primarily "stretching", the postures or poses ('asanas'), comprise just one of eight components of a broader discipline of comprehensive physical, mental, and spiritual health and balance for individuals. However, many types of yoga do not include or do not emphasize stretching or postures, and are not considered Hatha yoga. (Sivananda, 1999; Yogananda, 1998) Modern Hatha yoga usually includes other classical yoga components such as breathing exercises ('pranayama'), concentration (pratyhara), and mindfulness/meditation (dhyana). (Iyengar, 1979) Thus, a typical Hatha yoga program consists of an instructor leading a group of students or practitioners through a series of yoga postures while performing deep breathing exercises for. Most classes last 60-90 minutes, and the instructor demonstrates the correct posture for practitioners, and provides verbal suggestions that encourage practitioners focus their attention or concentrate on deep breathing, postural alignment, on bodily sensations produced by the asanas. Depending on their training and often the class setting, instructors often encourage students to embrace positive cognitions or attitudes towards the world and themselves. This usually occurs at the beginning or end of the session and the instructors model these attitudes as well. Some yoga instructional centers provide a more complete social and spiritual community in which

There are many different types of Hatha yoga (Ashtanga, Anusara, Viniyoga, Bikram, etc). These styles or schools of Hatha yoga differ on variables such as pace, or the amount of time

surgery. These 17 had significantly decreased neurological symptoms and pain.

"success" rates for surgery for low back pain only range from 40% - 65%.

the additional components of classical yoga are also practiced.

after the initial anesthetic injection.

**3. Yoga** 

spent in each pose, the extent to which deep breathing is emphasized, level of emphasis on proper bodily alignment, room temperature, spiritual emphasis, meditation time, and the overall intensity and difficulty of the poses. Hundreds or possibly thousands of postures and variations have been developed over time, each one designed to stretch, strengthen, or engage specific areas of the body. When modified, Hatha yoga can be practiced by almost anyone, not just the healthy and flexible. This can be achieved by the use of props which enables people of all ages and ability levels (physical and mental) to perform poses that achieve benefit. (Iyengar, 1979) Yoga can be tailored to people with various physical or psychological limitations and can range from gentle to strenuous, with some types of yoga providing a cardiovascular workout, and others focused on relaxation and a calm mind. To be improve physical and mental health, the practice of yoga is usually performed at least once per week (twice is recommended), with increasing frequency of practice either at home or in a class, and gradual practice of more advanced postures as conditioning improves and strength increases. (Stiles, 2000)

The popularity of yoga has grown tremendously in recent years. Data from the National Center for Complementary and Alternative Medicine (NCCAM) show that the usage of complementary and alternative medicine (CAM) treatments for all conditions is on the rise in the US. Back pain is the most common condition for which CAM treatments are sought. Yoga was the 5th most commonly used CAM treatment and its use increased significantly between 2002 and 2007. Yoga was used by 6.1% of all US adults and 2.1% of all children in the use in 2007.

#### **Broader effectiveness of yoga therapies**

Although there are many studies claiming yoga can be an effective treatment for improving a wide variety of conditions (musculoskeletal problems, (Greendale, McDivit, Carpenter, Seeger, & Huang, 2002) cardiopulmonary function, (Raub, 2002) lipid and carbohydrate metabolism, (Bera & Rajapurkar, 1993) sleep problems, (Harinath et al., 2004) anxiety and depression, (Waelde, Thompson, & Gallagher-Thompson, 2004) ) study quality has been lacking, with a clear need for larger randomized, controlled trials (RCTs). (Luskin et al., 2000) The limitations of most previous yoga studies include being nonrandomized, a lack of validated outcome measures, a lack of data on dose response, and little examination of the underlying mechanisms. In addition, the yoga interventions being studied are often not well described. Yoga is multi-dimensional, so it is important to describe all of the components of each yoga intervention in order to compare across interventions and better understand which components are best for different disease populations. More recently, some larger, higher quality randomized studies have been conducted in areas including depression, (Sharma, Das, Mondal, Goswampi, & Gandhi, 2005) stress and anxiety, (Granath, Ingvarsson, von Thiele, & Lundberg, 2006; Smith, Hancock, Blake-Mortimer, & Eckert, 2007) HIV, (Brazier, Mulkins, & Verhoef, 2006) irritable bowel syndrome, (Kuttner et al., 2006) and chronic low back pain. (Sherman et al., 2011; Tilbrook et al., 2011) With very few exceptions, these more recent trials indicate that yoga has demonstrable beneficial effects, is rarely harmful, and is well received by participants with a wide variety of health problems. The psychological benefits of yoga are almost as well established as the physical benefits, as suggested by studies on stress, anxiety, and depression.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 339

Table 1. Continued

In summary, chronic low back pain affects millions of people on a daily basis, and while there are many treatment options, none stand out as being highly effective. Yoga is a promising inexpensive alternative for treating CLBP with few anticipated side effects. It has moderate effectiveness and the next section reviews the published literature in more detail, including two large RCTs that were recently published.

#### **4. Literature review: Yoga for chronic low back pain**

#### **The impact of yoga on physical functioning and disability**

Almost all studies of yoga intervention for treating chronic low back pain measure physical functioning/disability as a primary outcome. It is viewed as a more reliable and objective measure of CLBP because it is often either measured by actual physiological performance, or by questionnaires with items that are tied to specific behaviors. Pain severity is typically an internal experience and more subjective. Virtually all studies measuring functioning/disability have demonstrated beneficial effects of yoga among adults with CLBP. (See Table 1) In 2004, Galantino et al. conducted a small randomized controlled trial to assess the impact of Hatha yoga on chronic low back pain. (Galantino et al., 2004) Participants were randomized to either the yoga group, consisting of twice-weekly, 60 minute, yoga classes for 6 weeks, or a wait-list control. Outcomes related to physical functioning included flexibility as assessed with the forward reach and sit and reach tests, and disability as assessed with the Oswestry Disability Index. Results of this study demonstrated non-significant trends towards improved balance and flexibility and decreased disability for the yoga group. However, sample size and participant attrition weakened this study's power, demonstrating the need for larger studies assessing the impact of yoga on chronic low back pain. Additionally, the 6-week yoga program is shorter than the 10-12 week programs that are most frequently studied.

Williams et al. conducted a randomized controlled trial to assess the impact of Iyengar yoga therapy in participants with non-specific chronic low back pain. (K. A. Williams et al., 2005) The study compared a standardized yoga intervention to an educational control group. Both the intervention group and the control group programs were 16 weeks long. Both groups received 16 weekly newsletters on back care, and two lectures of occupational/physical therapy education regarding chronic low back pain with instructional handouts. The yoga intervention consisted of one 90-minute class each week for 16 weeks at a community yoga studio, and participants were encouraged to practice yoga at home for 30-min, 5 days a week. Study results revealed less functional disability in the yoga group than in the control group at the post-treatment assessment.

The efficacy of a week-long intensive residential yoga program on disability caused by pain and spinal flexibility in patients with chronic low back pain was studied by Tekur et al. (Tekur, Singphow, Nagendra, & Raghuram, 2008) Eighty participants who were previously admitted to a health home in Bangalore, India were randomized to yoga and control groups. The yoga group followed a daily routine of meditation, yogic physical practices, yogic hymns, lectures on yogic lifestyle, yogic breathing, deep relaxation, counseling, and meditation with yogic chants. The control group followed a daily routine of exercise, nonyogic safe breathing exercises and lectures on causes of back pain, stress and chronic low back pain, and benefits of physical exercises. Control participants also watched video shows

In summary, chronic low back pain affects millions of people on a daily basis, and while there are many treatment options, none stand out as being highly effective. Yoga is a promising inexpensive alternative for treating CLBP with few anticipated side effects. It has moderate effectiveness and the next section reviews the published literature in more detail,

Almost all studies of yoga intervention for treating chronic low back pain measure physical functioning/disability as a primary outcome. It is viewed as a more reliable and objective measure of CLBP because it is often either measured by actual physiological performance, or by questionnaires with items that are tied to specific behaviors. Pain severity is typically an internal experience and more subjective. Virtually all studies measuring functioning/disability have demonstrated beneficial effects of yoga among adults with CLBP. (See Table 1) In 2004, Galantino et al. conducted a small randomized controlled trial to assess the impact of Hatha yoga on chronic low back pain. (Galantino et al., 2004) Participants were randomized to either the yoga group, consisting of twice-weekly, 60 minute, yoga classes for 6 weeks, or a wait-list control. Outcomes related to physical functioning included flexibility as assessed with the forward reach and sit and reach tests, and disability as assessed with the Oswestry Disability Index. Results of this study demonstrated non-significant trends towards improved balance and flexibility and decreased disability for the yoga group. However, sample size and participant attrition weakened this study's power, demonstrating the need for larger studies assessing the impact of yoga on chronic low back pain. Additionally, the 6-week yoga program is shorter

Williams et al. conducted a randomized controlled trial to assess the impact of Iyengar yoga therapy in participants with non-specific chronic low back pain. (K. A. Williams et al., 2005) The study compared a standardized yoga intervention to an educational control group. Both the intervention group and the control group programs were 16 weeks long. Both groups received 16 weekly newsletters on back care, and two lectures of occupational/physical therapy education regarding chronic low back pain with instructional handouts. The yoga intervention consisted of one 90-minute class each week for 16 weeks at a community yoga studio, and participants were encouraged to practice yoga at home for 30-min, 5 days a week. Study results revealed less functional disability in the yoga group than in the control

The efficacy of a week-long intensive residential yoga program on disability caused by pain and spinal flexibility in patients with chronic low back pain was studied by Tekur et al. (Tekur, Singphow, Nagendra, & Raghuram, 2008) Eighty participants who were previously admitted to a health home in Bangalore, India were randomized to yoga and control groups. The yoga group followed a daily routine of meditation, yogic physical practices, yogic hymns, lectures on yogic lifestyle, yogic breathing, deep relaxation, counseling, and meditation with yogic chants. The control group followed a daily routine of exercise, nonyogic safe breathing exercises and lectures on causes of back pain, stress and chronic low back pain, and benefits of physical exercises. Control participants also watched video shows

including two large RCTs that were recently published.

**4. Literature review: Yoga for chronic low back pain The impact of yoga on physical functioning and disability** 

than the 10-12 week programs that are most frequently studied.

group at the post-treatment assessment.


Table 1. Continued


Table 1. Studies that examined the effect of yoga on functioning/disability.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 341

on animals, plants, nature, etc. Outcomes included spinal mobility, as measured using a dialtype goniometer, and the Oswestry Disability Index. Results showed a significant difference between groups in disability, with the yoga group experiencing a greater decrease in disability than the control group. Spinal flexion, spinal extension, and left lateral flexion, increased in both groups, with the yoga group showing a greater increase in flexibility than the control group. Greater improvements were also found in straight leg raises for right and left

In 2009, Telles et al. presented results of a randomized control trial examining the effect of yoga on musculoskeletal discomfort and motor functions in professional computer users in India (n = 291). (Telles, Dash, & Naveen, 2009) Employees who used a computer for at least 6 hours each day, 5 days a week were randomized into a yoga intervention, or waitlist control. The yoga group participated in an hour of yoga practice each day, 5 days per week. Employees in the wait-list control spent the hour in a recreation center. Both groups were assessed at baseline and after 60 days on hand grip strength, tapping speed, and low back and hamstring flexibility. The yoga group demonstrated significant increases in handgrip strength for both hands and significant improvements in low back and hamstring flexibility. Results also

Williams et al. published additional results on the effectiveness of Iyengar yoga on chronic low back pain in 2009. (Williams et al., 2009) In this study, a total of 90 participants were randomized to the yoga intervention (n = 43) and wait-list control (n = 47) groups. The yoga intervention consisted of biweekly, 90-minute, Iyengar yoga classes over a 24 week period. Yoga participants were also asked to practice 30 minutes of yoga at home on non-class days, and were given props, a DVD, and an Iyengar yoga instruction manual. Participants in the control group continued their standard medical care, and were offered the yoga classes 6 months after the conclusion of the study. Individuals randomized to the yoga group showed greater improvements in functional disability than those randomized to the control group. Differences between the yoga and control groups were even stronger when limiting analyses to "completers" (30 individuals who completed the yoga intervention per protocol and 43 individuals not lost to follow-up in the waitlist control). Williams et al. (2009) report several limitations to their study, including reliance only on self-report measures, minimal disability among one-third of the participants, and the yoga group received greater attention

In 2010, Cox et al. led a small randomized controlled pilot study (n=20) with the goal of informing a larger multicenter trial on the effectiveness of yoga for chronic low back pain. (Cox et al., 2010) The study compared 12 weekly, 75-minute, yoga back classes with usual care. As part of the study, a yoga manual was developed for yoga practitioners and their students. Outcomes including the Roland-Morris Disability Scale were assessed at baseline, 4 and 12 weeks following randomization. No significant effects were found, as the pilot study was not powered to detect differences. The study did provide useful data for the

In 2010, Evans et al. studied the predictors of outcomes in individuals who self-selected yoga or physical therapy to treat chronic low back pain. (Evans et al., 2010) Specifically, yoga participants (n = 27) were recruited from a series of five 6-week, once weekly, yoga classes offered through a hospital based complementary and alternative medicine clinic.

legs for yoga group. (Tekur, Chametcha, Hongasandra, & Raghuram, 2010).

demonstrated group differences in changes in tapping speed following the 60 days.

and group support than did individuals from the control group.

larger study on feasibility of recruitment, attendance, and retention.

Table 1. Studies that examined the effect of yoga on functioning/disability.

on animals, plants, nature, etc. Outcomes included spinal mobility, as measured using a dialtype goniometer, and the Oswestry Disability Index. Results showed a significant difference between groups in disability, with the yoga group experiencing a greater decrease in disability than the control group. Spinal flexion, spinal extension, and left lateral flexion, increased in both groups, with the yoga group showing a greater increase in flexibility than the control group. Greater improvements were also found in straight leg raises for right and left legs for yoga group. (Tekur, Chametcha, Hongasandra, & Raghuram, 2010).

In 2009, Telles et al. presented results of a randomized control trial examining the effect of yoga on musculoskeletal discomfort and motor functions in professional computer users in India (n = 291). (Telles, Dash, & Naveen, 2009) Employees who used a computer for at least 6 hours each day, 5 days a week were randomized into a yoga intervention, or waitlist control. The yoga group participated in an hour of yoga practice each day, 5 days per week. Employees in the wait-list control spent the hour in a recreation center. Both groups were assessed at baseline and after 60 days on hand grip strength, tapping speed, and low back and hamstring flexibility. The yoga group demonstrated significant increases in handgrip strength for both hands and significant improvements in low back and hamstring flexibility. Results also demonstrated group differences in changes in tapping speed following the 60 days.

Williams et al. published additional results on the effectiveness of Iyengar yoga on chronic low back pain in 2009. (Williams et al., 2009) In this study, a total of 90 participants were randomized to the yoga intervention (n = 43) and wait-list control (n = 47) groups. The yoga intervention consisted of biweekly, 90-minute, Iyengar yoga classes over a 24 week period. Yoga participants were also asked to practice 30 minutes of yoga at home on non-class days, and were given props, a DVD, and an Iyengar yoga instruction manual. Participants in the control group continued their standard medical care, and were offered the yoga classes 6 months after the conclusion of the study. Individuals randomized to the yoga group showed greater improvements in functional disability than those randomized to the control group. Differences between the yoga and control groups were even stronger when limiting analyses to "completers" (30 individuals who completed the yoga intervention per protocol and 43 individuals not lost to follow-up in the waitlist control). Williams et al. (2009) report several limitations to their study, including reliance only on self-report measures, minimal disability among one-third of the participants, and the yoga group received greater attention and group support than did individuals from the control group.

In 2010, Cox et al. led a small randomized controlled pilot study (n=20) with the goal of informing a larger multicenter trial on the effectiveness of yoga for chronic low back pain. (Cox et al., 2010) The study compared 12 weekly, 75-minute, yoga back classes with usual care. As part of the study, a yoga manual was developed for yoga practitioners and their students. Outcomes including the Roland-Morris Disability Scale were assessed at baseline, 4 and 12 weeks following randomization. No significant effects were found, as the pilot study was not powered to detect differences. The study did provide useful data for the larger study on feasibility of recruitment, attendance, and retention.

In 2010, Evans et al. studied the predictors of outcomes in individuals who self-selected yoga or physical therapy to treat chronic low back pain. (Evans et al., 2010) Specifically, yoga participants (n = 27) were recruited from a series of five 6-week, once weekly, yoga classes offered through a hospital based complementary and alternative medicine clinic.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 343

yoga group had significantly greater improvements than the usual care group in backfunction at 3, 6, and 12 month follow-up. The authors conclude that a 12 week yoga intervention leads to greater improvements in back function than usual care treatment for

A number of studies, including many of the studies discussed above, also demonstrate the effectiveness of yoga in reducing pain in individuals with chronic low back pain. For example, in addition to studying yoga's effect on functional disability, Williams et al. (2005) also assessed clinical levels of pain, pain-related fears of movement, and pain attitudes. Their results suggested that in addition to the yoga group having less functional disability at post treatment, the yoga group demonstrated two times greater reductions in pain, than the

Beginning in 2005, military veterans who began attending a clinical yoga program at a large VA medical center in California completed a battery of health questionnaires before and after attending a 10-week yoga program. Baseline data and 10-week follow-up data were available for 33 participants as of August 2007. Statistically significant improvements were found for pain between baseline and 10-weeks. Among the various indicators of the amount of yoga practiced, correlations indicated that actual attendance was significantly correlated with decreased pain. These effects were found despite the fact that some participants did not attend regularly and the sessions were only offered once per week. Participants were encouraged to practice yoga postures at home and self-reports of the frequency of home practice were also associated with improvements in back pain. Further analyses with an expanded sample (n = 53) from the same study indicate that women improved more than men in the yoga program after controlling for baseline differences. Female participants had significantly greater improvements than male participants for "average" pain levels. No differences were found between men and women for pain "at its worst"or a total pain score.

Saper et al. (2009) also found greater decreases in pain scores for yoga participants than the control group from baseline to 12 weeks. The yoga group participants also reported larger global improvements in back pain at week 12 than control group participants. Results from this pilot study also provide support for the feasibility of recruiting, retaining, and treating a sample of predominantly minority adults for a 12 week yoga intervention. However, a number of limitations exist for this study. The small sample size limited their statistical power, there was substantial attrition to long-term follow-up in the yoga group, and many non-study treatments including yoga were used by the control group, making it difficult to

As discussed above, Telles et al. presented results of a randomized control trial examining the effect of yoga on musculoskeletal discomfort and motor functions in professional computer users (n = 291). (Telles, Dash, & Naveen, 2009) At the end of 60 days, they found greater decreases in the degree of interference due to musculoskeletal discomfort in the yoga group. Limitations noted by the authors include a high attrition rate from the follow-up assessment in both groups, but attrition rates did not differ between the groups. Of the 57 individuals who dropped out from the yoga group, only 6 did so because they preferred to use the 60-minute period for a recreational activity of their choosing. A second limitation of

Women and men did not differ on attendance or home practice.

draw conclusions from their 26-week data.

up to 12 months.

control group.

**The impact of yoga on pain** 

Physical therapy participants (n = 26) were recruited from 1 private and 1 hospital-based outpatient physical therapy clinic. Participants completed a clinical and demographic questionnaire at baseline and again after 6 weeks of treatment. Results suggested no significant group differences in treatment effect on disability at 6 weeks. However, their results indicated that self-efficacy was the most important predictor of disability and health status at 6 weeks for both groups. Additionally, the authors found a group by self-efficacy interaction upon predicting disability at 6 weeks. Specifically, self-efficacy was a stronger predictor of disability at 6 weeks for the physical therapy group. Because participants selfselected into the yoga or physical therapy group, a significant limitation of this study rests in fact self-selection bias may explain the differences in outcomes between the groups.

In 2011, Ülger and Yağli studied the effects of yoga on balance and gait in women (n = 27) with musculoskeletal disorders including low back pain and osteoarthritis. (Ülger and Yağli, 2011) The effect of 8 sessions of yoga treatment was assessed on gait (gait cycle, walking speed, maximum walking distance, step length, and ambulation index) and balance evaluations. Results suggested participants' gait parameters improved statistically following the 8 week yoga intervention. Additionally, improvements were also observed in the balance parameters. Although the authors conclude yoga has positive effects on physical problems such as gait and balance, significant limitations to this study include the absence of a control group/intervention, and small sample size. It is thus difficult to attribute the improvements in gait/balance to their yoga intervention.

Two larger randomized trials have recently been published in 2011 regarding yoga on chronic low back pain. Sherman et al. compared three different approaches designed to decrease the negative effects of back pain on participants' (n = 228) lives. (Sherman et al., 2011) Specifically, a series of yoga classes were compared to stretching exercises and to a self-care book. Yoga and stretching series consisted of twelve standardized, weekly 75-minute classes. Interviews were conducted at baseline and at 6, 12, and 26 weeks after randomization. Results suggested similar effects for yoga and stretching in individuals with low back pain. Back-related dysfunction declined over time in all groups, with the yoga group and stretching group reporting superior function than the self-care group at follow up assessments. At 12 weeks, the yoga group was significantly less bothered by symptoms than the self-care group. Both the yoga and stretching groups were more likely to rate their back pain as improved at all followup times, and were more likely to report being very satisfied with their care. Consequently, Sherman et al. suggest that yoga's benefits are largely attributable to the physical benefits of stretching and strengthening the muscles and not to its mental components.

In another study, Tillbrook et al. compared the effectiveness of yoga and usual care for chronic or recurrent low back pain using patients (n = 313) from 13 non-National Health Service premises in England, using long-term follow-up methods. (Tilbrook et al., 2011) The yoga intervention consisted of twelve 75-minute classes (1 class per week). Yoga participants were given a student manual, a mat, a relaxation compact disc which featured four narrated guided relaxations, and home practice sheets delivered at four intervals. Yoga participants were encouraged to use the compact disc, and to practice yoga for 30-minutes daily or to practice at least 2 times per week. All participants received a back pain education booklet and usual care. Additionally, fidelity assessments were used to ensure fidelity to the standardized treatment. Outcomes were measured before randomization, at baseline, and at 3, 6, and 12 months follow-up. Results suggested the yoga group had significantly greater improvements than the usual care group in backfunction at 3, 6, and 12 month follow-up. The authors conclude that a 12 week yoga intervention leads to greater improvements in back function than usual care treatment for up to 12 months.

#### **The impact of yoga on pain**

342 Low Back Pain

Physical therapy participants (n = 26) were recruited from 1 private and 1 hospital-based outpatient physical therapy clinic. Participants completed a clinical and demographic questionnaire at baseline and again after 6 weeks of treatment. Results suggested no significant group differences in treatment effect on disability at 6 weeks. However, their results indicated that self-efficacy was the most important predictor of disability and health status at 6 weeks for both groups. Additionally, the authors found a group by self-efficacy interaction upon predicting disability at 6 weeks. Specifically, self-efficacy was a stronger predictor of disability at 6 weeks for the physical therapy group. Because participants selfselected into the yoga or physical therapy group, a significant limitation of this study rests in fact self-selection bias may explain the differences in outcomes between the groups.

In 2011, Ülger and Yağli studied the effects of yoga on balance and gait in women (n = 27) with musculoskeletal disorders including low back pain and osteoarthritis. (Ülger and Yağli, 2011) The effect of 8 sessions of yoga treatment was assessed on gait (gait cycle, walking speed, maximum walking distance, step length, and ambulation index) and balance evaluations. Results suggested participants' gait parameters improved statistically following the 8 week yoga intervention. Additionally, improvements were also observed in the balance parameters. Although the authors conclude yoga has positive effects on physical problems such as gait and balance, significant limitations to this study include the absence of a control group/intervention, and small sample size. It is thus difficult to attribute the

Two larger randomized trials have recently been published in 2011 regarding yoga on chronic low back pain. Sherman et al. compared three different approaches designed to decrease the negative effects of back pain on participants' (n = 228) lives. (Sherman et al., 2011) Specifically, a series of yoga classes were compared to stretching exercises and to a self-care book. Yoga and stretching series consisted of twelve standardized, weekly 75-minute classes. Interviews were conducted at baseline and at 6, 12, and 26 weeks after randomization. Results suggested similar effects for yoga and stretching in individuals with low back pain. Back-related dysfunction declined over time in all groups, with the yoga group and stretching group reporting superior function than the self-care group at follow up assessments. At 12 weeks, the yoga group was significantly less bothered by symptoms than the self-care group. Both the yoga and stretching groups were more likely to rate their back pain as improved at all followup times, and were more likely to report being very satisfied with their care. Consequently, Sherman et al. suggest that yoga's benefits are largely attributable to the physical benefits of

In another study, Tillbrook et al. compared the effectiveness of yoga and usual care for chronic or recurrent low back pain using patients (n = 313) from 13 non-National Health Service premises in England, using long-term follow-up methods. (Tilbrook et al., 2011) The yoga intervention consisted of twelve 75-minute classes (1 class per week). Yoga participants were given a student manual, a mat, a relaxation compact disc which featured four narrated guided relaxations, and home practice sheets delivered at four intervals. Yoga participants were encouraged to use the compact disc, and to practice yoga for 30-minutes daily or to practice at least 2 times per week. All participants received a back pain education booklet and usual care. Additionally, fidelity assessments were used to ensure fidelity to the standardized treatment. Outcomes were measured before randomization, at baseline, and at 3, 6, and 12 months follow-up. Results suggested the

improvements in gait/balance to their yoga intervention.

stretching and strengthening the muscles and not to its mental components.

A number of studies, including many of the studies discussed above, also demonstrate the effectiveness of yoga in reducing pain in individuals with chronic low back pain. For example, in addition to studying yoga's effect on functional disability, Williams et al. (2005) also assessed clinical levels of pain, pain-related fears of movement, and pain attitudes. Their results suggested that in addition to the yoga group having less functional disability at post treatment, the yoga group demonstrated two times greater reductions in pain, than the control group.

Beginning in 2005, military veterans who began attending a clinical yoga program at a large VA medical center in California completed a battery of health questionnaires before and after attending a 10-week yoga program. Baseline data and 10-week follow-up data were available for 33 participants as of August 2007. Statistically significant improvements were found for pain between baseline and 10-weeks. Among the various indicators of the amount of yoga practiced, correlations indicated that actual attendance was significantly correlated with decreased pain. These effects were found despite the fact that some participants did not attend regularly and the sessions were only offered once per week. Participants were encouraged to practice yoga postures at home and self-reports of the frequency of home practice were also associated with improvements in back pain. Further analyses with an expanded sample (n = 53) from the same study indicate that women improved more than men in the yoga program after controlling for baseline differences. Female participants had significantly greater improvements than male participants for "average" pain levels. No differences were found between men and women for pain "at its worst"or a total pain score. Women and men did not differ on attendance or home practice.

Saper et al. (2009) also found greater decreases in pain scores for yoga participants than the control group from baseline to 12 weeks. The yoga group participants also reported larger global improvements in back pain at week 12 than control group participants. Results from this pilot study also provide support for the feasibility of recruiting, retaining, and treating a sample of predominantly minority adults for a 12 week yoga intervention. However, a number of limitations exist for this study. The small sample size limited their statistical power, there was substantial attrition to long-term follow-up in the yoga group, and many non-study treatments including yoga were used by the control group, making it difficult to draw conclusions from their 26-week data.

As discussed above, Telles et al. presented results of a randomized control trial examining the effect of yoga on musculoskeletal discomfort and motor functions in professional computer users (n = 291). (Telles, Dash, & Naveen, 2009) At the end of 60 days, they found greater decreases in the degree of interference due to musculoskeletal discomfort in the yoga group. Limitations noted by the authors include a high attrition rate from the follow-up assessment in both groups, but attrition rates did not differ between the groups. Of the 57 individuals who dropped out from the yoga group, only 6 did so because they preferred to use the 60-minute period for a recreational activity of their choosing. A second limitation of

Yoga as a Treatment for Low Back Pain: A Review of the Literature 345

chronic low back pain. Results suggested that both self-selected groups decreased pain medication use by similar amount (52% and 57% among yoga physical therapy groups, respectively). In the largest study of the impact of yoga on medication use to date, Sherman et al. found greater decreases in medication use in the yoga group when compared to self-

The broader effectiveness of yoga to the psychological well being of participants has been debated. Results from the literature are not yet conclusive regarding whether yoga can improve participants' psychological well being. For example, in 2004, Galantino et al. also assessed the impact of Hatha yoga on depression as assessed with the Beck Depression Inventory. Results of this study demonstrated non-significant trends towards decreased depression for the yoga group. However, sample size and participant attrition weakened this study's power, demonstrating the need for larger studies assessing the impact of yoga

Groessl et al. also reported the influence of yoga on the psychological well being of participants among San Diego veterans. The study found significant improvements in depression as measured with the CES-D 10, and the Mental Health Scale of the SF-12. Among the various indicators of the amount of yoga practiced, correlations indicated that self-reported

Williams et al. (2009) also reported on the impact of Iyengar yoga on the psychological well being of participants with chronic low back pain. Specifically, in reducing depression among individuals with chronic low back pain. Using the Beck Depression Inventory, individuals randomized to the yoga group showed greater improvements in depression than those randomized to the control group. As mentioned above, differences between the yoga and

In 2010, Tekur et al. (Tekur, Chametcha, Hongasandra, & Raghuram, 2010) presented additional results from their 2008 study. The authors used the WHOQOL Bref psychological subscale to measure the impact of yoga on mental health. They found significantly greater improvements in WHOQOL Bref psychological subscale for the yoga group compared with the control group. However, the intervention included many more elements (formal meditation, interactive lectures, spirituality) than the typical Hatha yoga interventions being studied in the other research we have reviewed, and the benefits were documented only at 7

Two studies by the same research group in the UK measured psychological impact with the Short From 12 Mental Component Scale (SF-12 MCS). The earlier pilot found no significant differences but has little power (n =20) to detect differences. The Tilbrook study was adequately powered but found non-significant trends toward greater improvements among

A variety of other outcomes were measured across the studies that have been reviewed. Some were very specific to the population being studied such as hand tapping speed for computer programmers. Other measures such as health-related quality of life were

home practice was significantly correlated with improved outcomes for depression.

control groups were even stronger when limiting analyses to "completers".

care, but no difference between the yoga and stretching groups.

**Psychological impacts of yoga** 

on chronic low back pain.

days after baseline.

**Other outcomes** 

the yoga group at 3- and 6-month assessments.

measured in a number of studies and are not study specific.

the intervention they studied was the high level of commitment required to sustain a 5 day/week, 60-minute, yoga practice on working days.

The 2009 study by Williams et al. discussed earlier also demonstrated the effectiveness of Iyengar yoga on improving pain for individuals with chronic low back pain. (K. Williams et al., 2009) Individuals randomized to the yoga group showed greater improvements in pain intensity than those randomized to the control group. Differences between the yoga and control groups were even stronger when limiting analyses to "completers" (30 individuals who completed the yoga intervention per protocol and 43 individuals not lost to follow-up in the waitlist control).

The Cox et al. study in 2010 measured pain-related outcomes using the Aberdeen Back Pain Scale and pain efficacy. At the 4-week follow-up, the yoga group reported greater decreases in pain. At both follow-up points, a non-significant trend in the yoga group showing an improvement in pain self-efficacy over the usual care group was observed. The results of the large RCT published by the same research group found no significant differences in pain severity at any assessment periods. They did find greater improvements in pain self-efficacy for the yoga group at 3 & 6 month follow-ups than those randomized to usual care.

In 2010, Evans et al. studied back pain bothersomeness, and back pain self-efficacy, in individuals who self-selected yoga or physical therapy to treat chronic low back pain. Results suggested no significant group differences in treatment effect on pain at 6 weeks. Their results also indicated that self-efficacy was the most important predictor of pain and health status at 6 weeks for both groups. Finally, Sherman et al. measured pain "bothersomeness" instead of pain severity because of the more subjective nature of reporting pain severity. Results indicate that the yoga group had significantlygreater reductions in pain "bothersomeness" than the self-care group at 12 weeks. However, they found similar effects of yoga on pain for yoga and stretching groups. Similar to the disability outcomes, both groups had reductions in pain after participating in the interventions.

#### **Medication use**

Five of the studies reviewed reported the effectiveness of yoga on reducing the use of medications. The results of Williams (2005) suggest a greater decrease in the use of pain medications than the control group. Saper et al. (2009) also reported on the beneficial effects of yoga on the use of medications. They found that the use of pain medicine differed significantly between the yoga and control groups such that the yoga participants decreased their use of pain medicine while the control group did not change. Opiate analgesic use increased for the control group participants, but decreased to zero for the yoga participants—another statistically significant difference between groups. Williams et al. (2009) found non-significant reductions in pain medication use at 12 and 24 weeks that was comparable in both their yoga group participants, and their control group who continued self-directed standard medical care. However, Williams et al. report a trend for the yoga group to have a higher success rate in decreasing their use of pain medication than at both 12 and 24 weeks follow up than the control group. Subgroup analyses that examined the use of pain medication in participants with moderate disability at baseline indicate that yoga participants with moderate disability showed a significantly greater reduction in pain medication at 12 weeks than their control group counterparts. In 2010, Evans et al. studied pain medication use in individuals who self-selected yoga or physical therapy to treat chronic low back pain. Results suggested that both self-selected groups decreased pain medication use by similar amount (52% and 57% among yoga physical therapy groups, respectively). In the largest study of the impact of yoga on medication use to date, Sherman et al. found greater decreases in medication use in the yoga group when compared to selfcare, but no difference between the yoga and stretching groups.

#### **Psychological impacts of yoga**

344 Low Back Pain

the intervention they studied was the high level of commitment required to sustain a 5-

The 2009 study by Williams et al. discussed earlier also demonstrated the effectiveness of Iyengar yoga on improving pain for individuals with chronic low back pain. (K. Williams et al., 2009) Individuals randomized to the yoga group showed greater improvements in pain intensity than those randomized to the control group. Differences between the yoga and control groups were even stronger when limiting analyses to "completers" (30 individuals who completed the yoga intervention per protocol and 43 individuals not lost to follow-up

The Cox et al. study in 2010 measured pain-related outcomes using the Aberdeen Back Pain Scale and pain efficacy. At the 4-week follow-up, the yoga group reported greater decreases in pain. At both follow-up points, a non-significant trend in the yoga group showing an improvement in pain self-efficacy over the usual care group was observed. The results of the large RCT published by the same research group found no significant differences in pain severity at any assessment periods. They did find greater improvements in pain self-efficacy

In 2010, Evans et al. studied back pain bothersomeness, and back pain self-efficacy, in individuals who self-selected yoga or physical therapy to treat chronic low back pain. Results suggested no significant group differences in treatment effect on pain at 6 weeks. Their results also indicated that self-efficacy was the most important predictor of pain and health status at 6 weeks for both groups. Finally, Sherman et al. measured pain "bothersomeness" instead of pain severity because of the more subjective nature of reporting pain severity. Results indicate that the yoga group had significantlygreater reductions in pain "bothersomeness" than the self-care group at 12 weeks. However, they found similar effects of yoga on pain for yoga and stretching groups. Similar to the disability outcomes, both groups had reductions in pain after participating in the interventions.

Five of the studies reviewed reported the effectiveness of yoga on reducing the use of medications. The results of Williams (2005) suggest a greater decrease in the use of pain medications than the control group. Saper et al. (2009) also reported on the beneficial effects of yoga on the use of medications. They found that the use of pain medicine differed significantly between the yoga and control groups such that the yoga participants decreased their use of pain medicine while the control group did not change. Opiate analgesic use increased for the control group participants, but decreased to zero for the yoga participants—another statistically significant difference between groups. Williams et al. (2009) found non-significant reductions in pain medication use at 12 and 24 weeks that was comparable in both their yoga group participants, and their control group who continued self-directed standard medical care. However, Williams et al. report a trend for the yoga group to have a higher success rate in decreasing their use of pain medication than at both 12 and 24 weeks follow up than the control group. Subgroup analyses that examined the use of pain medication in participants with moderate disability at baseline indicate that yoga participants with moderate disability showed a significantly greater reduction in pain medication at 12 weeks than their control group counterparts. In 2010, Evans et al. studied pain medication use in individuals who self-selected yoga or physical therapy to treat

for the yoga group at 3 & 6 month follow-ups than those randomized to usual care.

day/week, 60-minute, yoga practice on working days.

in the waitlist control).

**Medication use** 

The broader effectiveness of yoga to the psychological well being of participants has been debated. Results from the literature are not yet conclusive regarding whether yoga can improve participants' psychological well being. For example, in 2004, Galantino et al. also assessed the impact of Hatha yoga on depression as assessed with the Beck Depression Inventory. Results of this study demonstrated non-significant trends towards decreased depression for the yoga group. However, sample size and participant attrition weakened this study's power, demonstrating the need for larger studies assessing the impact of yoga on chronic low back pain.

Groessl et al. also reported the influence of yoga on the psychological well being of participants among San Diego veterans. The study found significant improvements in depression as measured with the CES-D 10, and the Mental Health Scale of the SF-12. Among the various indicators of the amount of yoga practiced, correlations indicated that self-reported home practice was significantly correlated with improved outcomes for depression.

Williams et al. (2009) also reported on the impact of Iyengar yoga on the psychological well being of participants with chronic low back pain. Specifically, in reducing depression among individuals with chronic low back pain. Using the Beck Depression Inventory, individuals randomized to the yoga group showed greater improvements in depression than those randomized to the control group. As mentioned above, differences between the yoga and control groups were even stronger when limiting analyses to "completers".

In 2010, Tekur et al. (Tekur, Chametcha, Hongasandra, & Raghuram, 2010) presented additional results from their 2008 study. The authors used the WHOQOL Bref psychological subscale to measure the impact of yoga on mental health. They found significantly greater improvements in WHOQOL Bref psychological subscale for the yoga group compared with the control group. However, the intervention included many more elements (formal meditation, interactive lectures, spirituality) than the typical Hatha yoga interventions being studied in the other research we have reviewed, and the benefits were documented only at 7 days after baseline.

Two studies by the same research group in the UK measured psychological impact with the Short From 12 Mental Component Scale (SF-12 MCS). The earlier pilot found no significant differences but has little power (n =20) to detect differences. The Tilbrook study was adequately powered but found non-significant trends toward greater improvements among the yoga group at 3- and 6-month assessments.

#### **Other outcomes**

A variety of other outcomes were measured across the studies that have been reviewed. Some were very specific to the population being studied such as hand tapping speed for computer programmers. Other measures such as health-related quality of life were measured in a number of studies and are not study specific.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 347

1). The two most informative studies have been published in recent months and have not been included in previous reviews. Each of these recent studies found that yoga improved function more than usual care or self-care. The Sherman et al. study employed a three group design, and thus, provided important "comparative effectiveness" data by comparing yoga to an exercise program led by physical therapists. It is notable that was not statistically superior to this exercise intervention. The only other study that used a comparison group of proven efficacy was Evans et al who also found no significant differences on function/disability. Thus, we conclude that yoga may not be superior to other nonpharmacological interventions with moderate effects sizes. However, attendance and satisfaction rates were higher among the yoga group in the Sherman study, indicating that it

With the exception of a few smaller studies, yoga interventions have been shown to reduce pain severity or the "bothersomeness" of pain, when compared with usual care, or information alone (See Table 2). In looking at the recent RCTs, the Sherman study found that yoga patients were less bothered by low back pain than self-care patients, while the Tilbrook study found no significant differences in back pain severity. The Tilbrook finding is a bit surprising, even though self-reported pain severity is different than pain bothersomeness. Sherman et al. specifically chose to measure pain bothersomeness because self-reported pain severity may be harder to measure reliably across various groups. It is also possible that the design of the Tilbrook study (13 different private practices across the UK) may have affected the results obtained. This may have resulted in greater heterogeneity among the instructors, intervention, or participants, and it is unclear whether the statistical analysis accounted for

Our review also suggests that yoga can reduce reliance on pain medication when compared with usual or self-care. However, only a few studies have published results on these outcomes so conclusions remain more tentative (See Table 3). With the exception of the Williams at el study, very little information is provided on how medication was measured. Measuring medication use poses its own challenges, with self-reported interview data often differing from medical record information or pill counts. Future research should consider other methods for measuring medication usage including the use of medical record

Depression and other indicators of the impact of yoga on psychological outcomes were assessed in a small number of studies (See Table 4). Significant effects were found in a few of the smaller studies, but only non-significant trends were found for the SF-12 MCS in the fullscale trial in which they were measured. The Sherman study did not publish data on psychological variables in their initial manuscript but these results may be forthcoming. Given the cognitive and relaxation components of yoga, along with the higher rates of depression among individuals with chronic low back pain, further research in this area is very important. We also reviewed the safety of yoga for some of the larger randomized controlled trials. Data from the largest and most recent trials suggests that two serious adverse events occurred among a combined total of 243 participants. These events were related to increased back pain, one being a herniated disc. Another 10% of these yoga participants experienced non-serious adverse events that were almost exclusively increases in back pain. Thus, participating in yoga interventions by persons with chronic low back pain is not without risk, but the vast majority of participants had no problems and experienced considerable

may be a more attractive intervention to many individuals.

clustering with the 13 cohorts.

information when possible.

benefit for a chronic debilitating condition.

#### **Safety of yoga**

It is important to address the concern that yoga could potentially be harmful to those with chronic low back pain. Popular media has tapped into this concern, often with anecdotal stories of dangers and injury, but little data. Like other exercise activity, the risks of injury from improperly performing yoga postures likely vary depending on how, where, and with whom the yoga is practiced. The initial practice of yoga under the direction of experienced yoga instructors is preferable to simply reading a book or following a video at home, and many of the programs being studied have been modified specifically for people with the condition of chronic low back pain. For optimal safety, people with either acute or chronic health conditions should consult their physician before starting a yoga program.

Data from research studies with experienced yoga instructors have shown occasional adverse events. The 2005 Sherman et al. study reported no serious adverse events. Of 36 patients assigned to the yoga group, one patient discontinued yoga because it precipitated migraines. Similarly, of 35 patients in the exercise group, one individual in the exercise group discontinued the intervention because of a back strain. Data from the Williams et al. study in 2005 show one serious adverse event among 30 patients randomized to yoga. This patient had symptomatic osteoarthritis and herniated a disc during the study. However, the event was reviewed by a medical panel and it was determined that the event was not caused by practicing yoga in this study. A larger, more recent study by Sherman et al. found equal numbers of mild to moderate adverse events in the yoga and stretching interventions, with temporary increases in back pain the leading cause. One serious adverse event, a herniated disc occurred among the 87 yoga participants. The other recent large RCT by Tilbrook et al. found 1 serious adverse event and 12 nonserious events among 156 yoga participants, all related to increased back pain. The more general review of nonpharmacological treatments for chronic low back pain concluded that these interventions seldom cause harm, but better studies and better reporting are needed (Chou & Huffman, 2007b).

#### **5. Discussion**

Chronic low back pain is an extremely prevalent condition that results in a great deal of lost productivity, disability, discomfort, and reduced quality of life for those afflicted. CLBP patients have higher health care costs in both the short-term and long-term.

Current treatments for CLBP are variable in the quality of evidence supporting them and in their overall levels of effectiveness. Medication management works for some patients but others require stronger narcotic agents which heighten the risk of addiction. None of the non-pharmacologic treatments stand out as clearly superior. With the exception of exercise and yoga, most of the treatments with solid supporting evidence and at least moderately sized effects are performed in a one-on-one provider setting or require expensive equipment. Thus, treatment modalities such as spinal manipulation, physical therapy, acupuncture, etc. may be more expensive than yoga or exercise interventions that can be delivered in group format, or once learned, can be self-administered at home. Actual data and cost analyses on yoga interventions for chronic low back pain are needed.

Our review of the current literature indicates that yoga has reduced disability and improved daily functioning in most studies when compared with usual care, or information alone. Most studies use one of two well-validated measures of functioning/disability, and some studies also included physiological measures such as grip strength and flexibility (See Table

It is important to address the concern that yoga could potentially be harmful to those with chronic low back pain. Popular media has tapped into this concern, often with anecdotal stories of dangers and injury, but little data. Like other exercise activity, the risks of injury from improperly performing yoga postures likely vary depending on how, where, and with whom the yoga is practiced. The initial practice of yoga under the direction of experienced yoga instructors is preferable to simply reading a book or following a video at home, and many of the programs being studied have been modified specifically for people with the condition of chronic low back pain. For optimal safety, people with either acute or chronic

Data from research studies with experienced yoga instructors have shown occasional adverse events. The 2005 Sherman et al. study reported no serious adverse events. Of 36 patients assigned to the yoga group, one patient discontinued yoga because it precipitated migraines. Similarly, of 35 patients in the exercise group, one individual in the exercise group discontinued the intervention because of a back strain. Data from the Williams et al. study in 2005 show one serious adverse event among 30 patients randomized to yoga. This patient had symptomatic osteoarthritis and herniated a disc during the study. However, the event was reviewed by a medical panel and it was determined that the event was not caused by practicing yoga in this study. A larger, more recent study by Sherman et al. found equal numbers of mild to moderate adverse events in the yoga and stretching interventions, with temporary increases in back pain the leading cause. One serious adverse event, a herniated disc occurred among the 87 yoga participants. The other recent large RCT by Tilbrook et al. found 1 serious adverse event and 12 nonserious events among 156 yoga participants, all related to increased back pain. The more general review of nonpharmacological treatments for chronic low back pain concluded that these interventions seldom cause harm, but better

Chronic low back pain is an extremely prevalent condition that results in a great deal of lost productivity, disability, discomfort, and reduced quality of life for those afflicted. CLBP

Current treatments for CLBP are variable in the quality of evidence supporting them and in their overall levels of effectiveness. Medication management works for some patients but others require stronger narcotic agents which heighten the risk of addiction. None of the non-pharmacologic treatments stand out as clearly superior. With the exception of exercise and yoga, most of the treatments with solid supporting evidence and at least moderately sized effects are performed in a one-on-one provider setting or require expensive equipment. Thus, treatment modalities such as spinal manipulation, physical therapy, acupuncture, etc. may be more expensive than yoga or exercise interventions that can be delivered in group format, or once learned, can be self-administered at home. Actual data

Our review of the current literature indicates that yoga has reduced disability and improved daily functioning in most studies when compared with usual care, or information alone. Most studies use one of two well-validated measures of functioning/disability, and some studies also included physiological measures such as grip strength and flexibility (See Table

health conditions should consult their physician before starting a yoga program.

studies and better reporting are needed (Chou & Huffman, 2007b).

patients have higher health care costs in both the short-term and long-term.

and cost analyses on yoga interventions for chronic low back pain are needed.

**Safety of yoga** 

**5. Discussion** 

1). The two most informative studies have been published in recent months and have not been included in previous reviews. Each of these recent studies found that yoga improved function more than usual care or self-care. The Sherman et al. study employed a three group design, and thus, provided important "comparative effectiveness" data by comparing yoga to an exercise program led by physical therapists. It is notable that was not statistically superior to this exercise intervention. The only other study that used a comparison group of proven efficacy was Evans et al who also found no significant differences on function/disability. Thus, we conclude that yoga may not be superior to other nonpharmacological interventions with moderate effects sizes. However, attendance and satisfaction rates were higher among the yoga group in the Sherman study, indicating that it may be a more attractive intervention to many individuals.

With the exception of a few smaller studies, yoga interventions have been shown to reduce pain severity or the "bothersomeness" of pain, when compared with usual care, or information alone (See Table 2). In looking at the recent RCTs, the Sherman study found that yoga patients were less bothered by low back pain than self-care patients, while the Tilbrook study found no significant differences in back pain severity. The Tilbrook finding is a bit surprising, even though self-reported pain severity is different than pain bothersomeness. Sherman et al. specifically chose to measure pain bothersomeness because self-reported pain severity may be harder to measure reliably across various groups. It is also possible that the design of the Tilbrook study (13 different private practices across the UK) may have affected the results obtained. This may have resulted in greater heterogeneity among the instructors, intervention, or participants, and it is unclear whether the statistical analysis accounted for clustering with the 13 cohorts.

Our review also suggests that yoga can reduce reliance on pain medication when compared with usual or self-care. However, only a few studies have published results on these outcomes so conclusions remain more tentative (See Table 3). With the exception of the Williams at el study, very little information is provided on how medication was measured. Measuring medication use poses its own challenges, with self-reported interview data often differing from medical record information or pill counts. Future research should consider other methods for measuring medication usage including the use of medical record information when possible.

Depression and other indicators of the impact of yoga on psychological outcomes were assessed in a small number of studies (See Table 4). Significant effects were found in a few of the smaller studies, but only non-significant trends were found for the SF-12 MCS in the fullscale trial in which they were measured. The Sherman study did not publish data on psychological variables in their initial manuscript but these results may be forthcoming. Given the cognitive and relaxation components of yoga, along with the higher rates of depression among individuals with chronic low back pain, further research in this area is very important.

We also reviewed the safety of yoga for some of the larger randomized controlled trials. Data from the largest and most recent trials suggests that two serious adverse events occurred among a combined total of 243 participants. These events were related to increased back pain, one being a herniated disc. Another 10% of these yoga participants experienced non-serious adverse events that were almost exclusively increases in back pain. Thus, participating in yoga interventions by persons with chronic low back pain is not without risk, but the vast majority of participants had no problems and experienced considerable benefit for a chronic debilitating condition.


Table 2. Studies that examined the effect of yoga on pain.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 349

Table 3. Studies that examined the effect of yoga on medication use.


Table 3. Studies that examined the effect of yoga on medication use.

Table 2. Studies that examined the effect of yoga on pain.


Table 4. Studies that examined the effect of yoga on psychological health.

Yoga as a Treatment for Low Back Pain: A Review of the Literature 351

Overall, our results are similar to and confirmatory of those published in a review article in 2011. This prior review was useful, but was released before the results of the two largest randomized controlled trials that have been published to date. Thus, we believed it was important to add these studies to the body of existing literature. We conclude that yoga interventions impact multiple outcomes that are important to the health and well-being of people afflicted with chronic low back pain. Recent, high quality evidence suggests that yoga provides comparable effects to, and is more appealing than, formal stretching and strengthening programs led by physical therapists. The recent data suggest that it would behoove health care organizations and the members they serve, to have yoga as an available

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350 Low Back Pain

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### *Edited by Ali Asghar Norasteh*

This book includes two sections. Section one is about basic science, epidemiology, risk factors and evaluation, section two is about clinical science especially different approach in exercise therapy. I envisage that this book will provide helpful information and guidance for all those practitioners involved with managing people with back pain-physiotherapists, osteopaths, chiropractors and doctors of orthopedics, rheumatology, rehabilitation and manual medicine. Likewise for students of movement and those who are involved in re-educating movement-exercise physiologists, Pilates and yoga teachers etc.

Low Back Pain

Low Back Pain

*Edited by Ali Asghar Norasteh*

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