Mechanical Low Back Injuries

1
Mechanical Low Back Injuries

• An Integrated Approach of Functional Movement

2
Objectives

• To identify the underlying causes and mechanisms
  of mechanical low back pain
• To understand some of the physical, biomechanical
  and psychosocial impairments / approaches
  associated with mechanical low back pain
• To integrate the approaches into a clinical model
  and incorporate treatment strategies into the
  approach

3
Epidemiology

• Leading cause of disability in those under the
  age of 45
• 3rd major cause of disability in general
  following heart disease and arthritis
• About 70 of all adults have low back pain (LBP)
  at some time in their life

• Most episodes of LBP resolve in 2-3 months
  (80-90)
• Recurrence rates are about 50 in the following
  12 months
• 5-10 of people with LBP develop chronic LBP (gt3
  months)

(Mannon et al, 2002 OSullivan, 2000)
4
Epidemiology (contd)

• Upto 85 of low back clients cannot be given a
  definitive diagnosis
• It is assumed that these injuries are due to (1)
  musculoligamentous injuries or (2) degenerative
  changes

(Mannon et al, 2001)
5
Causes of Low Back Pain

• Infections
• Referred Pain
• Psychological
• Mechanical

• Rheumatologic
• Endocrine / Metabolic
• Neoplastic Disease
• Vascular / Hematologic

(Swenson et al, 1998)
6
Mechanical Low Back Pain

• Mechanical Low Back Pain can be defined as pain
  that appears to have been caused by a mechanical
  event (eg. Lifting, twisting, etc), and is
  aggravated by movement

(Gallagher, 2002)
7
Mechanical Causes of LBP

• Facet
• Disc
• Paraspinal Muscles
• Instability
• Ligaments
• Sacroiliac Joint
• Spondylolysis / spondylolisthesis
• Spinal stenosis

8
Facet Joints

• Degeneration of facet joints as a cause of low
  back pain was first postulated in 1933
• Theory continues to be controversial
• Suggested that accounts for upto 15-20 of
  clients with low back pain
• Nocioceptive nerve fibres have been identified in
  facet-joint capsules and in synovial and
  pericapsular tissue

(Hanley et al, 1999Swenson,1998)
9
Intervertebral Disc

• Easily imaged on MRI however degeneration and
  protrusion may be seen in upto 64 of
  asymptomatic adults
• Innervation of the disc has been well
  characterized
• The meningeal nerve branches supply the PLL
  outer layers of the annulus fibrosus (AF)
• The outer 1/3 of the AF is innervated with pain
  transmitting free nerve endings
• Evidence suggests that severely degenerated discs
  have more extensive innervation than normal discs

(Hanley et al,1999)
10
Disc (contd)

• Two most common causes of disc pain are annulus
  fibrosus tears and disc herniation
• Herniated discs cause compression on pain
  sensitive structures such as the outer 1/3 of the
  annulus, PLL, anterior dura, nerve root
  sinuvertebral nerve

(Hanley et al, 1999)
11
Ligaments

• 6 main ligaments Anterior longitudinal ligament
  (ALL), Posterior longitudinal ligament (PLL),
  Interspinous, Supraspinous, Ligamentum flavum
  Intertransverse
• Ligamentum flavum not sensitive to mechanical
  stimulation
• PLL sensitive to stimulation similar to that of
  the annulus fibrosus
• ? Injury to other ligaments cause pain due to
  stress on other pain sensitive structures that
  arises from ligament laxity

(Hanley et al, 1999)
12
Lumbar Spine Muscles

• Trunk muscles have been categorized into local
  and global muscle systems
• Local refers to deep muscles of the trunk (eg.
  Multifidus, QL, transversus abdominis,
  interspinales)
• Global refers to larger, more superficial muscles
  (eg. Other abdominal muscles, longissimus)

(Bergmark, 1989)
13
Muscles (contd)

• Muscles can be acutely injured or be due to
  overuse injuries
• A typical inflammatory response takes place when
  a muscle is injured

14
Instability

• Defined as an abnormal response to applied
  loads, characterized by motion in the motor
  segment beyond normal constraints or motion
  quality abnormalities
• Basic concept is that abnormally large
  intervertebral motions cause either compression
  and/or stretching of the neural elements or
  abnormal deformations of ligaments, joint
  capsules, annular fibres and end-plates, which
  all have a significant density of nocioceptors

(Panjabi,1992)
15
Sacroiliac Joint

• Controversial source of low back pain
• Constant debate regarding the amount of
  movement, the location of the axes and the
  vulnerability of the joint to dysfunction
• Certain authors believe that instability of the
  pelvic girdle can lead to low back pain

16
Sacroiliac Joint (contd)

• Instability again refers to a loss of the
  functional integrity of a system that provides
  stability
• In pelvic girdle, 2 systems that contribute to
  stability, the osteoarticularligamentous and
  myofascial
• These 2 systems have been referred to as form
  closure and force closure
• Together they provide a self locking mechanism

(Vleeming, 19901995)
17
Spondylolysis / Spondylolisthesis

• Spondylolysis refers to a defect / fracture in
  the pars interarticularis of arch
• Spondylolisthesis refers to a forward
  displacement of one vertebrae over another (with
  or without a fracture)
• Tissue of origin of pain is unknown
• Places many back tissues under stress including
  discs, facets, ligaments
• Fracture / defect itself could be source of pain

(Swenson, 1998)
18
Classification of LBP

• Many authors have attempted to classify LBP into
  categories to aid in treatment and clinical
  decision making
• 4 classifications appear in the literature that
  are widely used and thoroughly described

19
A Review of the Literature of Classification
Systems

• (Riddle, 1998) reviewed classification systems
  designed for the majority of patients with low
  back pain
• MEDLINE search
• Systems reviewed were those most relevant to
  physiotherapists
• 4 (of 11 found) were found to be most relevant
  and reviewed critically
• Most appropriate because most thoroughly
  described used in continuing education courses
  and practiceuse diagnostic terms familiar to
  physios

20
4 Approaches

• 1 developed by an orthopaedic surgeon
• 2 by physiotherapists
• 1 (Quebec Task Force Classification) by many
  medical and non-medical disciplines

21
Classification System of Bernard
Kirkaldy-Willis (1987)

• Developed by an orthopedic surgeon
• Pathology based system
• Purpose is to determine the pathology causing the
  problem
• 23 categories in 3 groups
• Strongly based on radiologic findings

22
Categories
23
Classification System by Delitto et al.
(19951997)

• Developed by a physiotherapist
• Clinical guideline index
• Purpose is to guide treatment
• Has 3 levels involving different types of
  clinical decisions

24
Classification Scheme
Physio
Referral
Consultation
Stage II
Stage III
Stage I
Extension Flexion Lateral Shift Immobilization Tra
ction Mobilization
Flexibilty Deficit Strength Deficit Cardio
Deficit Coord. Deficit Body Mech. Deficit
Activity Intolerance Work Intolerance
25
McKenzie Classification

• Developed by a physiotherapist
• Clinical guideline index
• Purpose is to guide treatment
• Has 13 categories

26
Patients with low back pain who do not have
serious pathology, severe sciatica
or neurological deficits
Postural Syndrome
4 Dysfunction Syndromes
7 Derangement Syndromes
Hip Joint Or SI Joint Problem
27
Quebec Task Force

• Developed by experts in many fields
• Judgement Approach
• Purpose is to guide clinical decision making,
  establish prognosis, for quality control and
  research
• Designed for patients with low back pain related
  to work injuries

28
1
LBP without radiation of pain below gluteal
folds, No neurological signs
2
LBP with radiation not beyond the knee, No
neurological signs
3
LBP with radiation below the knee, No
neurological signs
Work Related Disorders Of the Spine
4
LBP with lower extremity radiation and
Neurological signs
5
Presumptive compression of nerve roott based
on Radiographic tests (eg.instability, fracture)
For Categories 1-4
6
Compression of nerve root confirmed by
imaging Tests (eg. CT scan, MRI)
A - lt 7 days B 7 days-7 Weeks C - gt 7 weeks
7
Spinal stenosis confirmed with radiologic tests
Symptom Duration
8
Post surgical status, lt6 mos following surgery
9
Post surgical status, gt6 mos following surgery
For categories 1-4, 10, 11
10
Chronic pain syndrome, treatable active disease
has Been ruled out
W Working I - Idle
Work Status
11
Other diagnoses (eg. Metateses, visceral disease)
29
What System is Being Used?

• No studies available that indicate clinical use /
  preference
• 2001 study did examine physiotherapists reported
  management of acute and subacute LBP in Ontario

• 274 Ontario PTs surveyed whose weekly workload
  included more than 10 of people with LBP
• 3 areas assessment, treatment, beliefs
  regarding treatment
• 3 scenarios and questions related to assessment
  and treatment

(Li Bombardier, 2001)
30
Results

• Most respondents assessed to rule out red flags
• Assesment included observation, palpation, ROM,
  SLR, LE strength, reflexes, abdominal strength,
  extensor strength

• gt50 of the PTs reported would use other
  assessment techniques such as McKenzie, lumbar
  scan, SI testing, LE scan
• No mention of classifying based on a system
  (other than McKenzie)
• Treatment was also not based on a system

(LI Bombardier, 2001)
31
Risk Factors for Onset of LBP

• Age 25-45
• Male Sex
• Physical Work Factors such as heavy physical
  work (esp. lifting)
• Psychosocial Work Factors such as low workplace
  social support and low job satisfaction
• Previous back pain
• Low fitness level, obesity
• Smoking

(Hoogendoorn et al,2000Bombardier et al,1994)
32
Developmental
33
Age Related Changes

• As individuals age, their lumbar spines undergo
  changes that are fairly uniformly reflected by
  the population
• There is a natural biological process of aging in
  the lumbar spine
• A natural process occurs but things we do over
  the course of our lives can affect the process
  (eg. Exercise and osteoporosis)

34
Discs

• Becomes more fibrous, nucleus pulposus becomes
  drier / granular
• Therefore, less able to exert fluid pressure and
  transmit weight directly
• A greater share of the vertical load is borne by
  the anulus fibrosus and is subject to greater
  stresses

• Previously thought that discs loose their height
  as we age, now know height increases (10for
  females and 2for males)
• Loss of trunk stature is due to decreases in
  vertebral body heights

(Twomey Taylor,1985Bogduk Twomey,1991)
35
Vertebral Body

• An overall decrease in bone density and bone
  strength in vertebral bodies
• Related to changes in trabeculae
• A loss of horizontal trabeculae removes the
  bracing effect of the vertical trabeculae and the
  load bearing capacity of the central portion of
  the vertebral body weakens

• Vertebrae then have to rely more on cortical bone
  which fails sooner than trabeculae bone
• This reliance on cortical bone puts the vertebral
  body at greater risk for deformation and injury

(Bogduk Twomey,1991)
36
Facet Joints

• Cartilage exhibits cell hypertrophy
• Osteophytes often form

(Bogduk Twomey, 1991)
37
Clinical Implications

• The older spine is less flexible and compliant
  and reacts more slowly to conditions of sustained
  loading
• Extensive research exists pointing to effect of
  exercise on bone, education is our key role with
  regards to this
• Smoking affects the integrity of the disc as
  discussed earlier, again our role as educators is
  emphasized
• Education with regards to posture and body
  mechanics

38
Biomechanics
39
Biomechanical Function of the Spinal System

• To allow movements between body parts
• To carry loads
• To protect the spinal cord and nerve roots

(Panjabi,1992)
40
A Biomechanical Theory

• Proposed by Panjabi in 1992
• Based on in vitro experiments of the spine
• Attempts to explain the mechanics of spinal motion

(Panjabi, 1992)
41
Neutral Position

• Neutral Position the posture of the spine in
  which the overall internal stresses in the spinal
  column and the muscular effort to hold the
  posture are minimal

(Panjabi,1992)
42
Neutral Zone

• Neutral Zone (NZ) that part of the physiologic
  range of motion, measured from the neutral
  position, within which each spinal motion meets
  with minimal internal resistance

(Panjabi,1992)
43
Elastic Zone

• Elastic Zone (EZ) that part of the physiologic
  range, measured from the end of the neutral zone
  up to the physiologic limit within the EZ,
  spinal motion is produced against a significant
  internal resistance

(Panjabi,1992)
44
Important Points

• When spinal movement begins from neutral, spinal
  motion occurs first in the NZ, where it meets
  with minimal stiffness
• Movement is then through the EZ which displays an
  increasing amount of resistance to motion the
  ligaments develop the greatest amount of tension
• At this point these definitions only apply to the
  osseoligamentous spine (no muscles)
• Therefore stiffness only refers to ligament
  stiffness

(Panjabi,1992)
45
Importance of Neutral Zone

• Panjabis experiments revealed that changes in
  the size or amplitude of the neutral zone were
  more dramatic than were changes in overall ROM as
  progressively greater loads were applied to the
  spine
• He noted that changes in neutral zone provided a
  more sensitive indication of the onset of spinal
  injury

46
Panjabis Experiments

• Documented the load at which the NZ and ROM
  increased how they correlated with injury
• At a load of 6.3 kg dropped from 1 metre and
  aligned to produce compression/flexion, the NZ
  increased markedly while no significant changes
  was seen in overall ROM
• Thus when ligaments begin to fail, the NZ is the
  first parameter to increase instability is seen
  in the NZ, not in overall ROM

47
Effect of NZ Compromise

• Panjabi noted injuries at the onset of NZ
  instability / laxity
• Included ligament tears, disc injuries, ligament
  avulsion tears, compression fractures, torn facet
  joint capsules

(Panjabi,1992)
48
Types of NZ

• NZ is described as being of 2 types active and
  passive
• Passive can only be observed in experiments where
  muscles have been removed
• Active is seen in living or in vivo spine
• The size of the NZ is likely to be of smaller
  amplitude as the spinal muscles provide greater
  stiffness through this portion of the ROM
• Thus depending on the extent to which a persons
  musculature is working optimally, their spine may
  exhibit more or less movement in the NZ

(Panjabi,1992)
49
Neutral Zone Summary

• Overall spinal ROM is composed of motion through
  the NZ and EZ
• NZ is a region of low stiffness or laxity
• EZ is a region of high stiffness, which increases
  in a non-lonear fashion
• Increases in the amplitude or size of the NZ
  correlate with the onset of osseoligamentous
  injury in the in vitro spine
• The in vivo spine displays greater control over
  size of NZ through the stabilizing effect of
  muscles

50
Biomechanical Study

• In vivo experiment by McGill (1998)
• Trained powerlifters
• Video fluoroscopy, EMG (surface indwelling)
• Recording muscle action while subjects lifted
  heavy loads

51
Stabilizing Systems of the Spine
Control Subsystem Neural
Passive Subsystem Spinal Column
Active Subsystem Spinal Muscles
52
Passive System

• Ligaments do not provide stability to the spine
  in terms of motion within the NZ in this range
  they function as proprioceptors
• Ligaments likely provide stability only as
  movement approaches limit of the EZ
• Dysfunction of the passive system which could
  affect biomechanics include overstretching of the
  ligaments, annulus tears or fissures, endplate
  microfractures, disc extrusion into vertebral
  bodies
• All these factors decrease the load bearing and
  stabilizing capacity of the passive system

(Panjabi,1992)
53
Active System

• Muscles and tendons serve 2 functions within this
  model
• To provide stiffness or control of spinal motion
  through the NZ
• Proprioceptive feedback via GTOs and muscle
  spindles

(Panjabi,1992)
54
Neural System

• The CNS is provided with input from a variety of
  proprioceptors (GTOs, muscle spindles, joint
  mechanoreceptors)
• With this input the neural control subsytem
  determines specific reqirements for spinal
  stability, and causes the active system to
  achieve the stability goal
• The neural system monitors ligament stretch and
  muscle tension to assess the position and load of
  individual spinal motion segments and the column
  in general with this feedback, the control
  subsystem can alter the muscle forces acting
  across a spinal joint to affect an appropriate
  stability response

(Panjabi,1992)
55
Motor Control
56
Motor Control Issues

• Has been a growing amount of research in this
  area in the last decade
• Studies have identified a number of motor control
  issues which affect the overall stability of the
  lumbar spine
• Research is now starting to reveal how the
  central nervous system prepares and modulates the
  muscle system to support the lumbar spine and its
  segments for functional activity and load

57
Key Muscles

• Important muscles have been identified in the
  literature which play an important role in
  segmental stabilty
• These muscles are the deep muscles of the trunk
• Special attention has been paid to the multifidus
  and transversus abdominis muscles

58
Transversus Abdominis

• The deepest of the abdominal muscles
• A cylinder like muscle with attachments to the
  lumbar vertebrae via the thoracolumbar fascia
• When it contracts bilaterally it produces a
  drawing in of the abdominal wall, resulting in an
  increased pressure within the abdominal cavity
  and an increase in tension in the thoracolumbar
  fascia

(Richardson et al, 1999)
59
Main Deficits

• 3 main motor control problems identified in the
  Transversus Abdominis
• These muscles appear to lose their normal
  anticipatory function in patents with low back
  pain, exhibiting delays in activation thus a
  loss of normal preprogrammed function for support
• In contrast to patients without low back pain,
  the muscle appears to be unable to function
  independently of the other abdominal muscles in
  patients with low back pain
• Demonstrates phasic activity rather than the
  tonic activity required for its supporting role

60
A Motor Control Evaluation of Transversus
Abdominis
61
Multifidus

• Most medial of the lumbar muscles
• Unique arrangement of predominantly
  vertebra-to-vertebra attachments
• Predominantly Type I fibres (tonic role)
• Contributes to the support and control of the
  orientation of the lumbar spine and the support
  of the lumbar segments

62
Main Deficits

• Appears to react by inhibition at a segmental
  level in acute episodes of low back pain
• Slower activation/recruitment rendering the
  muscles too slow to meet the demands of joint
  protection

(Hodges,2000)
63
ExercisePhysiology
64
Inactivity Changes

• Low back pain leads to a variety of degenerative
  changes associated with inactivity
• This is further compounded if there is an
  extended time span between injury and admittance
  to rehab programs
• Changes can include muscular atrophy, decreased
  flexiblity and cardiovascular deconditioning

(Robert et al,1995)
65
Muscle Atrophy

• Dysfunction of the lumbar muscles in LBP patients
  has been demonstrated using imaging modalities
  that allow assessment of muscle size or cross
  sectional area and muscle consistency
• Atrophy in terms of decreased size of the
  paraspinal muscles has been demonstrated using
  imaging techniques
• Decreased muscle density, which can be a sign of
  muscle atrophy, is caused by fatty infiltration
  or actual fatty replacement of fibres
• Fatty degeneration of the multifidus and erector
  spinae has been found in chronic LBP patients and
  post operative patients

(Alaranta et al,1993Richardson et al,1999)
66

• In addition changes in the internal structure of
  the type I fibres of the multifidus have been
  demonstrated in LBP patients
• The fibres have been described as moth eaten in
  appearance
• Changes in the internal structure of type I
  fibres occur quickly (in biopsy specimens of
  subjects with a symptom duration of only 3 weeks)

(Richardson et al,1999)
67
Effects of Exercise on CSA of Multifidus in LBP
Patients
68
Effects of Work Hardening on Cardio Fitness
Muscle Strength
69
Motor Learning
70
Motor Learning

• A set of internal processes associated with
  practice or experience leading to a relatively
  permanent change in motor skill

(Schmidt Lee,1999)
71
Motor Learning LBP

• Very few, if any studies that look directly at
  motor learning principles
• Are studies that investigate body mechanics
  training and performance as well as studies that
  look at practice and ability to perform certain
  exercises
• In addition there are studies that investigate
  functional training vs. non functional physio and
  how this affects RTW and functional restoration

72
Motor Learning Stability

• Stage 1 The Cognitive Stage
• Stage 2 The Associative Stage
• Stage 3 The Autonomous Stage

73
Stage 1- Cognitive Stage

• A high level of awareness is demanded of subjects
  in order to isolate the co-contraction of
  specific muscles
• Aim of first stage is to train the specific
  isometric co-contraction of transversus abdominis
  and multifidus at low levels of maximal voluntary
  co-contraction
• Also to cease contraction of other muscle
  subsitution
• Training is suggested 1x/day(10-15 mins)
• Incorporate into functional tasks once achieved
• At this stage a degree of pain control is
  expected with postures a biofeedback for client

(OSullivan,2000)
74
Stage 2 Associative Stage

• Focus is on refining a particular movement
  pattern
• Aim is to identify 2 or 3 faulty or pain
  provocative movement patterns and break them down
  into component movements with high reps
• Patient does this while maintaning co-contraction
  of local muscles
• Can be performed for sit to stand, lifting, etc
• Patients do on a daily basis and increase speed
  and complexity

(OSullivan,2000)
75
Stage 3-Autonomous Stage

• A low degree of attention is required for the
  correct performance of the motor task
• The third stage is the aim of the exercise
  intervention, whereby patients can dynamically
  stabilize their spines appropriately in an
  automatic manner during the functional demands of
  daily living

(OSullivan,2000)
76
Effects of Practice on Stabilization Exs
77
Functional Restoration vs. Regular Physio

• Studies in the USA on the efficacy of FR are very
  positive regarding RTW rate
• Studies in Canada and Finland do not demonstrate
  as strong results
• Hypothesized difference could be due to lower
  economic benefits during sick leave in USA lead
  to favourable results from FR programs

78
Review of Literature

• Overall the programs are effective in returning a
  greater percentage of individuals to the
  workplace and in a more efficient manner (between
  21-52 improvement in the rate of RTW vs control
  groups)
• A review of the literature reveals the programs
  are effective for chronic and acute LBP
• 1 study examining reinjury reported that 48 of
  Rx group and 79 of control group had a
  reoccurence within 1 year
• Only 1 cost analysis study. The program resulted
  in an increase cost of 400/subject but there was
  a saving of 2000/subject in WCB costs, resulting
  in savings of 1600

(Lechner,1994Bendix,2000)
79
Motor Learning Summary

• Few studies exist in the LBP literature directly
  related to motor learning
• Studies / information is available that discusses
  different treatment methods that include aspects
  of practice
• Points to a need to research in motor learning in
  this area and to investigate what motor learning
  principles are being used in clinical practice

80
Psychosocial
81
Psychosocial Factors LBP

• Psychosocial factors play a crucial role in low
  back pain clients
• They play a particular important role in the
  transition from an acute injury to a chronic
  injury
• Seems to be personal and work psychosocial
  factors that affect LBP clients

82
Psychosocial Factors _at_ Work

• One,psychosocial work characteristics can
  directly influence the biomechanical load through
  changes in posture and movement
• Two,these factors may trigger physiological
  mechanisms, such as increased muscle tension or
  increased hormonal excretion, that may lead to
  organic changes or influence pain perception

(Hoogendoorn,2000)
83

• Three,psychosocial factors may change the ability
  of an individual to cope with an illness which
  could in turn influence the reporting of symptoms
• Four, the association may be confounded by the
  effect of the physical factors at work

(Hoogendoorn,2000)
84
Psychosocial Factors at Work

• A 2000 review of the literature found 6 reported
  psychosocial factors at work that influence LBP
• Work Pace
• Qualitative Demands
• Job Content
• Job Control
• Social Support in the Workplace
• Job Satisfaction

(Hoogendoorn,2000)
85
Work Pace

• 3 high quality studies
• 1 found no significant effect
• 1 found a statistically significant effect of a
  high work pace on back related short absenteeism
• 1 found a statistically significant effect of a
  high work pace on sciatic pain
• When rated the studies showed there is
  insufficient evidence of an effect of high work
  pace on the risk of pain, due to inconsistent
  findings

(Hoogendoorn,2000)
86
Qualitative Demands

• Include conflicting demands, interruption of
  tasks, and intense concentration for long periods
• 1 high and 1 low quality study
• 1 study found that high conflicting demands had a
  statistically significant effect on short and
  long absences from work due to pain
• When rated there is insufficient evidence of an
  effect of high qualitative demands on the risk of
  LBP

(Hoogendoorn,2000)
87
Job Content

• Includes monotonous work and work with few
  possibilities to learn new skills
• 4 high quality studies
• No statistically significant effect was found

(Hoogendoorn,2000)
88
Job Control

• Includes aspects such as autonomy and influence
• 2 high quality studies
• Both found no significant effect

(Hoogendoorn,2000)
89
Social Support in Workplace

• Includes social support of coworkers and
  supervisors, relationships at work and problems
  with coworkers and supervisors
• 5 high quality studies
• 4 of 5 showed that low support had a
  statistically significant effect
• Rating system showed that there is strong
  evidence for low social support in the workplace
  as a risk factor for back pain

(Hoogendoorn,2000)
90
Job Satisfaction

• 7 high and 2 low quality studies
• Researchers in 5 high quality studies found that
  low job satisfaction had a statistically
  significant effect
• Strong evidence for low job satisfaction as a
  risk factor for low back pain

(Hoogendoorn,2000)
91
Personal Psychosocial Factors

• The same review in 2000 examined the studies
  available on the effect of psychosocial factors
  in private life and there effect on LBP
• Only 1 high and 2 low quality studies were found
• Factors studied included family support, presence
  of a close friend, social contact, social
  participation and emotional support
• In general, no significant effect was found
• Application of the rating system found there is
  insufficient evidence of an effect of
  psychosocial factors in private life

(Hoogendoorn,2000)
92
Psychological Factors in the Development of
Chronic LBP

• Psychological factors in addition to being risk
  factors for LBP also appear to play a role in the
  development of chronicity in LBP
• A systematic review of the literature done by
  Pincus et al (2002) reviewed studies that
  investigated psychological factors as predictors
  of chronicity/disability in prospective cohorts
  of LBP

93
Method

• 6 studies met inclusion criteria
• Inclusion criteria prospective cohorts
  concerning LBPsubjects with acute or subchronic
  LBPmeasurement of at least 1 psychological
  variable at baseline
• Rated on 3 main criteria (methodologic quality,
  quality of measurement of psychological factors
  and quality of measurement of psychological
  factors)

94
Results

• 4 psychosocial factors are identified in the
  literature
• Psychological distress/Depressive Mood
• Somatization
• Personality
• Cognitive Factors

(Pincus,2002)
95
Psychological Distress / Depressive Mood

• Due to tools used in studies difficult to
  differentiate between psychological distress,
  depressive symptoms depressive moods
• Authors therefore used distress to represent a
  composite of all terms
• Distress is a significant predictor of
  unfavorable outcome
• This effect was independent of clinical factors,
  such as pain and function _at_ baseline

(Pincus et al,2002)
96
Somatization

• I high quality study and 1 acceptable study
• Somatization scales predict unfavorable outcomes

(Pincus et al, 2002)
97
Personality and Cognitive Factors

• Personality
• Minnesota Multiphasic Personality Inventory
  (MMPI) subscale of hysteria was reported to be a
  predictor of RTW in 1 study
• Overall quality rated low

• Cognitive Factors
• Dealt with coping strategies, fear avoidance,
  catastrophizing
• Studies had a low quality rating

(Pincus et al,2002)
98
Summary

• Distress and somatization are confirmed as having
  a role in the progression to chronicity in LBP
• 2 areas of psychological risk are surprisingly
  underrepresented fear avoidance and
  catastrophizing
• Authors commented that although it is felt that
  pain related fear and avoidance appear to be an
  essential feature of the development of
  chronicity, support from prospective studies is
  sparse
• Research regarding catastrophizing predicting
  disability is based on cross sectional studies or
  based on groups with different disorders

(Pincus et al,2002)
99
Functional Self Efficacy

• Refers to confidence judgments regarding the
  ability to execute or achieve tasks of physical
  performance
• Suggests that those having higher levels of FSE
  and believing they could perform functional tasks
  could be expected to reach higher levels of
  physical performance because they invest more
  effort and persistence and, consequently are less
  likely to become preoccupied with expectations of
  further pain and injury

(Lackner et al,1996)
100
FSE Chronic LBP Study

• Some interesting conclusions made by the authors
• A link between FSE and disability
• FSE has a predictive power
• Individuals with high FSE may be less prone to
  thoughts of future harm and may apply coping
  skills more effectively

(Lackner et al,1996)
101
An Overview of Treatment Approaches used in LBP
102
Interventions

• A wide range of interventions exist for the
  treatment of LBP
• These include
• Exercise
• Modalities
• Manual Therapy
• Education
• Functional Restoration Programs

103
Efficacy

• With the exception of exercise and functional
  restoration no evidence exists that substantiates
  effectiveness of the other interventions in a low
  back population
• Lack of evidence is mostly due to (a) lack of
  studies and (b) lack of high level studies

104
Exercise

• Literature seems to be divided into 2 groups
• General Exercise (stretching, strengthening,
  aerobic, McKenzie)
• Stabilization Exercise (specific to deep trunk
  muscles)

105
General Exercise

• A review was published in 2001 undertaken by the
  Philadelphia Panel
• The review evaluated 9 rehab interventions for
  LBP 1 being exercise
• Studies were eligible if they were RCTs,
  nonrandomized controlled clinical trials (CCTs),
  case control and cohort studies
• Studies had to evaluate exercise in nonspecific
  LBP and included post surgery
• Summarized exercise studies according to acute
  LBP, subacute LBP and chronic LBP

106
Exercise Acute LBP

• Acute defined as lt 4 weeks
• 4 RCTs
• Exercises included McKenzie, back extension,
  strengthening exs
• No efficacy was demonstrated
• Therapeutic exercises were no better than control
  for improving function, ability to work and pain
• Clinical Recommendations poor evidence to
  include or exclude stretching or strengthening
  exs alone as an intervention for acute LBP

107
Exercise SubAcute LBP

• Sub acute defined as 4-12 weeks
• 3 RCTs included
• Exercises included McKenzie, Flexion Exs,
  strengthening exs
• Clinically important benefits found with regards
  to pain relief, patient assessed global condition
  functional status
• Recommendations good evidence to include
  flexion, extension and strengthening exs as
  interventions for subacute LBP

108
Exercise Chronic LBP

• Chronic defined as gt 12 weeks
• 8 RCTs
• Exercises included flexion, extension,
  stretching, circuit training and strength exs
• Clinically important benefit was demonstrated for
  pain relief functional status
• Recommendations good evidence to include
  stretching, strengthening and mobility exs as
  interventions for chronic LBP

109
Stabilization Exercises

• A review was done by Gallagher (myself) in 2002
• Identified and reviewed literature available on
  exercise studies that incorporated the use of
  stabilization exercises
• Stabilization exercises was defined as exercises
  that incorporated training of the multifidus and
  transversus abdominis muscles

110
Summary of Literature

• 5 studies reviewed
• 3 RCTs and 2 single group designs
• Included studies of acute and chronic clients
• Clinically important benefits included pain
  relief, decreased disability and decreased muscle
  atrophy
• Recommendations Stabilization exs are
  recommended for acute and chronic clients to
  address pain, disability, muscle atrophy and
  possibly motor control issues

111
An Integration of Approaches in Clients with LBP
112
Biomechanics Clinical Implications

• As therapists we should
• Be aware of the neutral zone and factors that
  affect it
• Maintain neutral zone with stability exs
• Protect the joint with proper exercises and
  education on posture and ergonomics
• Help maintain muscle strength

113
Motor Control Clinical Implications

• As therapists we should
• Be aware of muscles most affected in LBP
• Provide exercises relevant to these affected
  muscles
• Measure outcomes as closely as possible
• Attempt to have patients minimize use of
  inappropriate muscles

114
Motor Learning Clinical Implications

• As therapists we should
• Provide practice and feedback for clients
• Encourage practice outside of treatment sessions
• If work related injuries, provide tasks /
  treatment that is specific to tasks they have to
  return to

115
Exercise Physiology Clinical Implications

• As therapists we should
• Be aware of effects of inactivity in the LBP
  client
• Enhance cardiovascular fitness of LBP clients
• Address muscle atrophy with specific exercise
  training

116
Psychosocial Clinical Implications

• As therapists we should
• Be aware of the factors that affect LBP and
  chronicity of LBP
• Identify factors that may be affecting a clients
  treatment / return to work
• Identify If work psychosocial factors are
  affecting treatment
• Attempt to increase functional self efficacy

117
An Integrated Model to Address Function in Low
Back Pain Clients

• Group Activity

118
Objectives

• To identify the underlying causes and mechanisms
  of mechanical low back pain
• To understand some of the physical, biomechanical
  and psychosocial impairments / approaches
  associated with mechanical low back pain
• To integrate the approaches into a clinical model
  and incorporate treatment strategies into the
  approach