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Mechanical Low Back Injuries


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Title: Mechanical Low Back Injuries

Mechanical Low Back Injuries
  • An Integrated Approach of Functional Movement

  • 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

  • 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
  • Recurrence rates are about 50 in the following
    12 months
  • 5-10 of people with LBP develop chronic LBP (gt3

(Mannon et al, 2002 OSullivan, 2000)
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

(Mannon et al, 2001)
Causes of Low Back Pain
  • Infections
  • Referred Pain
  • Psychological
  • Mechanical
  • Rheumatologic
  • Endocrine / Metabolic
  • Neoplastic Disease
  • Vascular / Hematologic

(Swenson et al, 1998)
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)
Mechanical Causes of LBP
  • Facet
  • Disc
  • Paraspinal Muscles
  • Instability
  • Ligaments
  • Sacroiliac Joint
  • Spondylolysis / spondylolisthesis
  • Spinal stenosis

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)
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
  • 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)
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)
  • 6 main ligaments Anterior longitudinal ligament
    (ALL), Posterior longitudinal ligament (PLL),
    Interspinous, Supraspinous, Ligamentum flavum
  • Ligamentum flavum not sensitive to mechanical
  • 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)
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,
  • Global refers to larger, more superficial muscles
    (eg. Other abdominal muscles, longissimus)

(Bergmark, 1989)
Muscles (contd)
  • Muscles can be acutely injured or be due to
    overuse injuries
  • A typical inflammatory response takes place when
    a muscle is injured

  • 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

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

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

(Vleeming, 19901995)
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)
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

A Review of the Literature of Classification
  • (Riddle, 1998) reviewed classification systems
    designed for the majority of patients with low
    back pain
  • MEDLINE search
  • Systems reviewed were those most relevant to
  • 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

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

Classification System of Bernard
Kirkaldy-Willis (1987)
  • Developed by an orthopedic surgeon
  • Pathology based system
  • Purpose is to determine the pathology causing the
  • 23 categories in 3 groups
  • Strongly based on radiologic findings

Classification System by Delitto et al.
  • Developed by a physiotherapist
  • Clinical guideline index
  • Purpose is to guide treatment
  • Has 3 levels involving different types of
    clinical decisions

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

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

LBP without radiation of pain below gluteal
folds, No neurological signs
LBP with radiation not beyond the knee, No
neurological signs
LBP with radiation below the knee, No
neurological signs
Work Related Disorders Of the Spine
LBP with lower extremity radiation and
Neurological signs
Presumptive compression of nerve roott based
on Radiographic tests (eg.instability, fracture)
For Categories 1-4
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
Spinal stenosis confirmed with radiologic tests
Symptom Duration
Post surgical status, lt6 mos following surgery
Post surgical status, gt6 mos following surgery
For categories 1-4, 10, 11
Chronic pain syndrome, treatable active disease
has Been ruled out
W Working I - Idle
Work Status
Other diagnoses (eg. Metateses, visceral disease)
What System is Being Used?
  • No studies available that indicate clinical use /
  • 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)
  • 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)
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)
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)

  • 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
  • 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)
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)
Facet Joints
  • Cartilage exhibits cell hypertrophy
  • Osteophytes often form

(Bogduk Twomey, 1991)
Clinical Implications
  • The older spine is less flexible and compliant
    and reacts more slowly to conditions of sustained
  • 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
  • Education with regards to posture and body

Biomechanical Function of the Spinal System
  • To allow movements between body parts
  • To carry loads
  • To protect the spinal cord and nerve roots

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)
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

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

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

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

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
  • He noted that changes in neutral zone provided a
    more sensitive indication of the onset of spinal

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

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

Types of NZ
  • NZ is described as being of 2 types active and
  • 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

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

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

Stabilizing Systems of the Spine
Control Subsystem Neural
Passive Subsystem Spinal Column
Active Subsystem Spinal Muscles
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
  • All these factors decrease the load bearing and
    stabilizing capacity of the passive system

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

Neural System
  • The CNS is provided with input from a variety of
    proprioceptors (GTOs, muscle spindles, joint
  • 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

Motor Control
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

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

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

(Richardson et al, 1999)
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

A Motor Control Evaluation of Transversus
  • 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

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

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)
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)
  • 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
  • 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)
Effects of Exercise on CSA of Multifidus in LBP
Effects of Work Hardening on Cardio Fitness
Muscle Strength
Motor Learning
Motor Learning
  • A set of internal processes associated with
    practice or experience leading to a relatively
    permanent change in motor skill

(Schmidt Lee,1999)
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
  • In addition there are studies that investigate
    functional training vs. non functional physio and
    how this affects RTW and functional restoration

Motor Learning Stability
  • Stage 1 The Cognitive Stage
  • Stage 2 The Associative Stage
  • Stage 3 The Autonomous Stage

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
  • Also to cease contraction of other muscle
  • 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

Stage 2 Associative Stage
  • Focus is on refining a particular movement
  • 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

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

Effects of Practice on Stabilization Exs
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

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
  • 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

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

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
  • Seems to be personal and work psychosocial
    factors that affect LBP clients

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

  • 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

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

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

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

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

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

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

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

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

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

  • 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

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

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

(Pincus et al, 2002)
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,
  • Studies had a low quality rating

(Pincus et al,2002)
  • 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
  • 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
  • Research regarding catastrophizing predicting
    disability is based on cross sectional studies or
    based on groups with different disorders

(Pincus et al,2002)
Functional Self Efficacy
  • Refers to confidence judgments regarding the
    ability to execute or achieve tasks of physical
  • 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)
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)
An Overview of Treatment Approaches used in LBP
  • A wide range of interventions exist for the
    treatment of LBP
  • These include
  • Exercise
  • Modalities
  • Manual Therapy
  • Education
  • Functional Restoration Programs

  • 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

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

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

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

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

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

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

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
  • Recommendations Stabilization exs are
    recommended for acute and chronic clients to
    address pain, disability, muscle atrophy and
    possibly motor control issues

An Integration of Approaches in Clients with LBP
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

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

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

Exercise Physiology Clinical Implications
  • As therapists we should
  • Be aware of effects of inactivity in the LBP
  • Enhance cardiovascular fitness of LBP clients
  • Address muscle atrophy with specific exercise

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

An Integrated Model to Address Function in Low
Back Pain Clients
  • Group Activity

  • 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
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