The Management of Low Back Pain: A Comprehensive ... · Low back pain (LBP) is a ubiquitous...

Chapter 15The Management of Low Back Pain:A Comprehensive RehabilitationProgramSusan C. Sorosky, MD

Brad Sorosky, MD

Joel M. Press, MD

IntroductionLow back pain (LBP) is a ubiquitous condition with a60% to 90% lifetime incidence and a 5% annual inci-dence. It is the most common cause of disability in theUnited States in people younger than 45 years of ageand is second to the common cold as the most frequentreason for visiting the doctor. The annual cost of manag-ing LBP is estimated to be a staggering $56 billion. Al-though 90% of episodes resolve without medical atten-tion in 6 to 12 weeks, 70% to 90% of patients with LBPhave recurrent episodes. Despite a decrease in symp-toms, these patients have anatomic and functionalchanges that increase their chance of reinjury. There-fore, it is essential that rehabilitation focuses not onlyon resolving the symptoms associated with injured andoverloaded tissues but also on identifying and rehabili-tating the unique associated biomechanical deficits andfunctional adaptations.

The benefits of exercise are profound and includeimproved cardiovascular fitness, muscle strength, flexi-bility, and endurance. Enhanced mood, increased paintolerance, and better sleep also have been found to berelated to exercise. There is also evidence that spine mo-tion improves disk health through more efficient deliv-ery of nutrients and removal of metabolic waste prod-ucts. Exercise appears to be relatively safe in patientswith LBP; there is no evidence that regular exercise in-creases the risk of additional back problems in patientswith acute, subacute, or chronic LBP. Exercise appearsto exert a neutral effect or may even slightly reduce therisk of future back injuries. On the other hand, bed resthas deleterious consequences in the setting of LBP, lead-ing to decreased cardiovascular fitness, muscularstrength, flexibility, bone density, and disk nutrition; in-creased spinal segment stiffness and depression are alsoassociated with inactivity. There is no proven benefit ofprolonged bed rest for patients with nonradicular pain.Therefore, no more than 2 days of absolute bed rest is

recommended for patients with nonspecific LBP. Rela-tive rest, which allows for short periods of rest betweenactivities and helps minimize the negative effects of bedrest, is actually preferred.

There are several reasons why the clinician shouldchoose rehabilitation techniques for patients with LBP.Rehabilitation techniques help resolve the clinicalsymptoms and signs created by a primary lumbar spineinjury so that active treatment encouraging indepen-dence can be initiated as soon as possible, and the unto-ward effects of inactivity can be minimized. By address-ing both the primary site of injury and secondary sitesof dysfunction, rehabilitation restores function, returnspatients to activity, and theoretically lessens the chanceof recurrence, thus optimizing outcome. Specifically, re-habilitation after a lumbar spine injury may help de-crease days lost from work or sports activities and mayincrease productivity. Rehabilitation of lumbar injuriesmust continue beyond resolution of symptoms so thatall other aspects of the injury complex, including flexi-bility, strength, power, and endurance, are fully rehabili-tated. A plan for prevention of recurrent episodes ofLBP is developed based on the comprehensive rehabili-tation program so that optimal physiologic and biome-chanical fitness is maintained; therefore, the risk of in-jury is potentially minimized.

Therapeutic Exercise and CardiovascularFitness, Flexibility, and StrengthIn addition to reducing the intensity of back pain andthe degree of disability related to back pain, the broadgoals of a rehabilitation program are to improve cardio-vascular fitness, flexibility, and strength, because deficitsin all of these areas have been found in patients withLBP. Cardiovascular training can result in enhanced me-tabolism of free fatty acids, less body fat, increased insu-lin sensitivity, improved blood flow to muscles, higher

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maximal cardiac output, greater VO2max (maximal oxy-gen consumption during exercise), lower heart rate for agiven level of exertion, and reduced blood lactate accu-mulation and minute ventilation at a given submaximallevel of exertion. In addition, studies suggest that indi-viduals who are more physically fit may have LBP lessoften than individuals who do not exercise. On the otherhand, aerobic conditioning is easily lost if a back injuryresults in more than 1 week of reduced activity. Specifi-cally, VO2max, the best indicator of aerobic fitness, de-creases by 25% after 3 weeks of bed rest. In addition,patients with chronic LBP have reduced aerobic capac-ity in comparison with healthy control patients; how-ever, it is unclear whether LBP reduces fitness or if re-duced fitness leads to LBP. Therefore, aerobic training isan important aspect of a comprehensive rehabilitationprogram. According to the American Heart Association(www.americanheart.org), in order to attain a high levelof cardiovascular fitness, exercise should be performedfor 30 to 60 minutes on most days of the week at 50%to 80% of one’s maximum capacity. Improvements incardiovascular fitness, as measured by a 10% to 20%increases in VO2max, usually can be noted within 8 to12 weeks of training implementation. Many studies havefound that patients with LBP are capable of improvingtheir aerobic capabilities.

Rehabilitation for patients with LBP is also gearedtoward improving flexibility, which is defined as theability to move a single joint or series of joints throughan unrestricted pain-free range of motion. Flexibility isdependent on the extensibility of muscles and connec-tive tissue that cross and surround a joint. General ben-efits of improved flexibility include increased availablejoint range of motion and reduced stress across one ormore joints. Patients with LBP may report feeling “lessstiff” and being able to perform activities of daily living(ADLs) and other work, sports, and/or leisure activitiesmore comfortably. To produce normal lumbar motion,flexibility must be present in the hip flexors, hip exten-sors, hip rotators, adductors, abductors, hamstrings,quadriceps, and the gastrocnemius-soleus complex. Anormal degree of flexibility of the hamstrings is re-quired for appropriate lifting and bending postures; aflexibility deficit in the hamstrings appears to be a pre-disposing factor in the development of LBP. Particularmuscles prone to tightness in patients with LBP includethe erector spinae, tensor fascia latae, iliopsoas, quadra-tus lumborum, and hamstrings. Also, deficits in lead hipinternal range of motion have been documented in golf-ers with LBP. Several methods of stretching exist, in-cluding static (steady force application over a period of15 to 60 seconds); ballistic (use of rapid force in a re-peated bouncing, throwing, or jerking maneuver); andproprioceptive neurofacilitation (techniques of hold-relax or contract-relax with or without agonist contrac-tion). More recently, functional stretching, which in-

cludes activity and sport-specific stretches performed ina dynamic manner in multiple planes of movement, hascome into favor. Despite the chosen stretching tech-nique, rapid high-force stretches, which produce tissuerecoil, should be avoided. Also, in patients with lumbarinstability, end-range flexibility exercises should beavoided to prevent further dysfunction and pain. In gen-eral, stretching is effective in restoring normal trunkrange of motion in patients with LBP. In patients withchronic LBP, flexibility training leads to a 20% averageimprovement in trunk flexibility.

The goal of a comprehensive rehabilitation programfor LBP is to correct muscle weaknesses and imbalanceswith strengthening exercises. Strength training has beenused as a successful strategy to reduce LBP and im-prove function. Other benefits include the potential forreduced risk of reinjury and an increased sense of well-being in patients with LBP. With complete bed rest,muscle has been shown to lose 1% to 3% of its strengthper day and 10% to 15% per week during the first2 weeks. Studies have shown that patients with chronicLBP have reduced strength and greater atrophy of theback muscles in comparison with healthy control pa-tients. A 70% loss in trunk muscle strength was found inpatients with lumbosacral pain persisting 6 months orlonger. More globally, strength of the core muscles hasbeen found to be preferentially affected in patients withLBP. Studies have reported that the multifidi musclesare atrophied in patients with LBP. A significant asym-metry in hip extensor strength was found in female ath-letes with LBP; there was an association between thisstrength imbalance and recurrence of LBP over the en-suing year. In addition to strength deficits, motor controlabnormalities have been identified in the core muscula-ture. Patients with LBP appear to have delayed activa-tion of the transversus abdominis. One study reported,that compared with control patients, patients with LBPhave delayed trunk muscle activation where the con-traction of all trunk muscles precede that of the muscleresponsible for lower limb movement; this delay wasconsistently and most significantly related to contractionof the transversus abdominis. Delayed firing and poorendurance of the gluteus maximus and medius have alsobeen found in patients with LBP. In contrast to thesefindings that demonstrate the importance of individualcore muscles, a more recent study reported that no mus-cle in isolation dominated in the enhancement of spinestability; each muscle’s individual role was continuouslychanging across tasks. Therefore, it was proposed thatglobal muscle activation by co-contraction of multipleagonist/antagonist muscles was preferable to trainingprimarily “local” muscles. In addition to the core muscu-lature, many other muscles are weak in patients withLBP, including the rectus femoris, vastus medialis andlateralis, tibialis anterior, and peroneus longus andbrevis.

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Strengthening exercises can be categorized into backextensor strengthening or core strengthening. Tradi-tional strengthening of the back extensors is based onthe progressive overload principle whereby increases inmuscle strength are associated with muscular hypertro-phy and enlargement of muscle cross-sectional area. Ex-amples of this type of exercise include back extensorstrengthening machines as well as roman chair exercises,which rely on one’s own body weight to strengthen theback extensors. A typical strengthening routine is com-posed of three sets of 8 to 12 repetitions, performedonce or twice a week; resistance should increase by nomore than 10% per week. Studies have shown that suchprogressive resistance training results in improvementsof 30% to 80% in volitional back muscle strength. It isunclear, however, whether these findings correlate withany functional benefits. In addition, although the humanbody functions in three cardinal planes (sagittal, frontal,and transverse), and back injury most commonly resultsfrom a combination of these motions, particularly flex-ion and torsion, these exercises are likely nonfunctionalbecause they are performed solely in the sagittal plane.

Core strengthening is now favored among rehabilita-tion specialists and has come to supersede other thera-peutic exercise regimens such as traditional back exten-sor strengthening. The core is the center of thefunctional kinetic chain and can be conceptualized as a“box” with the lumbar muscles (erector spinae and mul-tifidi), abdominals, (transversus abdominis, internal ob-lique, external oblique, and rectus abdominis), hip girdle(iliopsoas, gluteus maximus and medius, hamstrings, andthoracodorsal fascia), and quadratus lumborum com-prising the sides of the box. The diaphragm forms thetop and the pelvic floor forms the bottom of the box.The core can be thought of as a muscular corset thatworks as a unit to stabilize the body and spine with andwithout limb movement. Core strengthening (alsoknown as dynamic lumbar stabilization, motor control[neuromuscular] training, neutral spine control, andmuscular fusion) describes the training of muscular con-trol around the lumbar spine to maintain functional sta-bility. This type of exercise is based on the belief thatLBP is intimately linked with functional instability, de-fined as a significant decrease in the capacity of the sta-bilizing systems to maintain the neutral zone (the rangein which internal resistance from active muscular con-trol is minimal) within physiologic limits. Although in-tersegmental injury and intervertebral disk degenera-tion are associated with a larger neutral zone, muscularco-contraction of small intersegmental muscles andlarger, more “global” muscles provide active stiffness orstability, thereby making the zone smaller. Rehabilita-tion of the core also allows the multisegmented spinalcolumn to maintain its center of gravity through multi-

ple ranges of motion, counteracting gravity and appliedforces to decrease torsion and shear on spinal struc-tures.

In contrast to progressive resistance training of theback extensors, which form part of the core, corestrengthening involves more than simply making mus-cles strong. In fact, motor relearning of inhibited mus-cles may be more important than actual strengtheningin patients with LBP. According to one study, muscularendurance, not absolute strength, is the most importantfactor in maintaining a “margin of safety” for stability.This study specifically reported that only a very smallincrease in the activation of the multifidi and abdominalmuscles was required to stiffen spinal segments, includ-ing 5% of a maximum voluntary contraction for ADLsand 10% for rigorous activity. Contrary to the com-monly held notion, core strengthening is not equivalentto sit-ups and pelvic tilts. Traditional sit-ups are unsafebecause they cause increased compression loads on thelumbar spine; pelvic tilts may also increase spinal load-ing by decreasing lordosis. Moreover, these two tradi-tional exercises are nonfunctional. Instead, with corestrengthening, the focus is on a motor control modelwhereby specific deficits are identified and muscles thentrained to provide dynamic stability and segmental con-trol to the spine. Faulty movement patterns are targetedwith the components of the movement isolated and re-trained into functional tasks specific to the patient’sneeds. It is imperative that exercises progress fromtraining isolated muscles to training as an integratedunit to facilitate functional activity. Studies demonstrat-ing the efficacy of core strengthening in patients withLBP, along with a core strengthening protocol in thecontext of a comprehensive rehabilitation program forLBP, will be discussed in subsequent sections.

Evidence-Based Approach to SpecificTherapeutic Exercise Interventions forSpecific LBP DiagnosesSeveral advances have been made in the field of medi-cine to the understanding of identifying and managingpathology in the human body. For example, in the fieldof microbiology, hundreds of different disease-causingmicroorganisms have been discovered and specific anti-biotics developed for treatment of each microorganism.As a result of this knowledge, no longer are all infec-tions considered identical and managed simply with acourse of penicillin. Similarly, musculoskeletal clinicianshave also gained an appreciation of the various paingenerators causing LBP, including muscles, ligaments,facet joints, intervertebral disks, and spinal nerves.Therefore, it makes no more sense to manage all causesof LBP with the same set of exercises as it does to treatall infections with penicillin.

OKU: Spine 3 Chapter 15 The Management of Low Back Pain: A Comprehensive Rehabilitation Program


Although specific therapeutic exercise interventionshave been developed to address different diagnosticsubsets of LBP, guidelines regarding the effectiveness ofexercise for LBP, including the well-known CochraneDatabase of Systematic Reviews, are sometimes confus-ing and controversial. According to the Cochrane Data-base, there is strong evidence that exercise therapy is nomore effective than other active or even inactive treat-ments of acute LBP. In addition, there is conflicting evi-dence regarding the efficacy of exercise compared withinactive treatment for chronic LBP. Exercise therapy ap-pears to be more effective than the usual care providedby the general practitioner and equally effective as con-ventional physiotherapy. The studies cited by suchguidelines often contribute to misconceptions about thelack of efficacy of exercise for LBP because in many in-stances, a uniform exercise program was used irrespec-tive of an ill-defined underlying condition. As a result,what is demonstrated is that nonspecific treatments ofnonspecific diagnoses lead to nonspecific results. It isunreasonable to expect specific benefits from an exer-cise program if no specific diagnoses are made beforeinitiation of the treatment arm of a study. Furthermore,a physical therapy program that is not individualized toeach patient lessens the chance of successful rehabilita-tion of patients who have different causes of LBP. Insummary, absence of proof because of methodologicflaws in the available literature is not equivalent toproof that exercise has no beneficial effect.

Better designed studies exist in which diagnosticsubsets of patients with LBP are defined and treatmentsspecific for these diagnoses are evaluated. For example,in the literature, back pain is not considered a nebulousentity but rather a presentation with many different eti-ologies including mechanical, flexion based (for exam-ple, disk herniation), extension based (for example, facetpathology, spinal stenosis), and instability mediated. Inaddition, as opposed to a blanket approach to physicaltherapy, specific therapeutic exercise protocols such asthe McKenzie technique and core strengthening areevaluated in patients with LBP. In general, these studiesshow more promising results regarding the efficacy oftherapeutic exercise for the management of LBP. Forexample, the effectiveness and medical costs of a classi-fication approach to the rehabilitation of patients withacute, work-related LBP were compared with an ap-proach based on the Agency for Health Care Policy Re-search guideline that advocates a more general ap-proach for the first 4 weeks of rehabilitation. Jointmobilization or manipulation and spinal active range-of-motion exercises were assigned to those patients withunilateral symptoms who did not have signs of nerveroot compression and positive findings for either sacro-iliac joint dysfunction or asymmetric restriction of lum-bar side-bending motion and lumbar segmental hypo-mobility. Patients with a flexion pattern (preference for

sitting and centralization with lumbar flexion) weregiven lumbar flexion exercises while those with an ex-tension pattern (preference for standing and centraliza-tion with lumbar extension) were given lumbar exten-sion exercises. Trunk strengthening and stabilizationexercises were the treatment modalities for patientswith frequent previous episodes, a positive response toprior manipulation or bracing as treatment, the pres-ence of an “instability” catch, or lumbar segmental hy-permobility. Finally, patients with radicular signs that didnot centralize with movement who may have had a lat-eral shift deformity were given either mechanical trac-tion or autotraction. The findings of this study show thatclassification-based treatment results in significantlybetter outcomes for disability (at up to 1 year of follow-up), return to work, and patient satisfaction at 4 weekscompared with the guideline-based group; there wasalso a trend toward less cost with the more specifictreatment.

Several other studies have demonstrated the efficacyof two specific physical therapy regimens, movementtherapy based on the results of directional preferencetesting and core strengthening, for diagnostic subsets ofLBP. Directional preference testing is based on theMcKenzie technique of repetitive end-range lumbar testmovements, which have traditionally been shown to behelpful in evaluating the presence or absence of disco-genic pain. With this mechanical assessment, a clinicalphenomenon known as centralization commonly occurswhere the most distal extent of referred or radicularpain rapidly recedes toward the lumbar midline by asingle direction of repeated end-range movement. Forexample, with a discogenic etiology, the most commondirection of lumbar testing that centralizes pain is exten-sion, whereas a smaller group of patients will centralizeonly with laterally directed movements or even lumbarflexion. The recommended treatment then consists ofthat specific directional preference of end-range exer-cises and appropriate symptom-driven posture strate-gies.

There is strong evidence of good outcomes for cen-tralizers with this directionally driven treatment modal-ity. For example, patients with acute and subacute LBPwith or without radicular symptoms who might benefitfrom an extension-mobilization program based on cen-tralization with extension movements and positive find-ings from pelvic alignment tests were identified; thesepatients were then randomized to either an extension-based (with sacroiliac mobilization) or a flexion-basedexercise program. The extension group improved morerapidly per the modified Oswestry Low Back Question-naire, administered at days 3 and 5 of treatment. In ad-dition, one study found that a unidirectional exerciseprogram in extension with an additional focus on pos-ture and ergonomics had superior outcomes at 3 weeksand 1 year compared with education in a “mini back



school” in patients with acute LBP with or without radi-ating pain. In a review of 87 patients with LBP and radi-ating leg pain, it was reported that centralization oc-curred in 87% of such patients; the occurrence of thisphenomenon during initial mechanical evaluation wasan accurate predictor of successful treatment outcomeand a reliable determinant of the appropriate directionof treatment exercise. Nonoccurrence of centralization,however, accurately predicted poor treatment outcome.In a multicenter, randomized controlled trial of 312 pa-tients with acute or chronic LBP or sciatica with orwithout neurologic findings, a standardized mechanicalassessment was used to identify two groups of patients,based on the presence or absence of a directional pref-erence. The 230 patients who exhibited a lasting benefi-cial pain response to one particular movement werethen randomized to one of three exercise treatments in-cluding directional exercises “matching” the directionalpreference, exercises directionally “opposite” to the di-rectional preference, and nondirectional exercise. Al-though all three exercise treatment groups showed im-provement in all outcomes including pain intensity andmedication usage, there were significantly greater im-provements in every outcome in the group treated withmatched directional exercises compared with the othertreatment groups.

Many studies have reported beneficial outcomes fora core program in the management of lumbar disk her-niation, lumbar instability, and acute LBP. In one classicstudy, a dynamic lumbar stabilization or core strength-ening program for patients with lumbar radiculopathywas described. Good or excellent self-reported out-comes were obtained in 50 of 52 patients (96%) with astabilization and abdominal program, together with flex-ibility exercises, joint mobilization of the hip and thethoracolumbar spinal segments, gym training, and aero-bic activity. Another study then compared a specificcore strengthening “stability” protocol for treating pa-tients with chronic LBP secondary to instability fromspondylolysis and spondylolisthesis with a standardtreatment directed by the treating physician involvingsupervised exercise programs and modalities. The spe-cific exercise treatment program consisted of 10 weeksof training of the deep abdominal muscles, with co-activation of the lumbar multifidi proximal to the parsdefect; this activation was then incorporated into previ-ously aggravating static postures and functional tasks.The core strengthening group showed a statistically sig-nificant reduction in pain intensity and functional dis-ability levels, maintained at 30-month follow-up,whereas the control group demonstrated no significantchange. In a recent study, patients experiencing a first-time episode of acute LBP were randomly allocated to acontrol group receiving advice and medications or aspecific exercise group performing exercises targetingthe multifidus in co-contraction with the transversus ab-

dominis. The core strengthening group had fewer recur-rences of LBP in comparison with the nonexercisegroup at 1 year (30% versus 84%) and at 2 to 3 years(35% versus 75%). It can be concluded from these stud-ies on the McKenzie technique and core strengtheningthat therapeutic exercise leads to beneficial results forpatients with LBP if performed in a specific manner anddirected at a specific pain generator.

A Comprehensive Rehabilitation Program forLow Back PainThe clinician must have an understanding of the uniquebiomechanical stresses placed on the lumbar spine andits kinetic chain. A thorough patient history, physical ex-amination, and any appropriate radiologic studies willhelp facilitate a specific diagnosis including the potentialpain generator and any associated musculoskeletal dys-functions. A specific treatment approach, customized foreach patient’s unique presentation, can then be used forthe most optimum outcomes. A comprehensive rehabili-tation program seeks to reduce pain and inflammation,correct soft-tissue inflexibilities, and improve musclestrength deficits and imbalances as well as endurance inthe involved spinal segments and the entire kineticchain. Another important function of LBP rehabilitationis education and training for posture, body mechanics,and proprioception with the goal of maintaining thespine in the most optimal biomechanical position duringactivity. No single component of the rehabilitation pro-gram should be used in isolation, but rather in concertwith other appropriate components.

The Acute Phase of RehabilitationRehabilitation can be conceptualized as occurring inthree stages–acute, recovery, and maintenance; however,these phases are not time-dependent and tend to over-lap. During the acute stage of rehabilitation, goals areoriented toward decreasing the signs and symptoms ofthe injury (pain, swelling, stiffness, and other clinicalfindings). Before initiating a specific physical therapy in-tervention, the clinician should educate the patientabout the proposed etiology of their LBP and the rec-ommended treatment plan. A period of relative restmay also be suggested. Modalities such as ice or low-level heat wrap therapy, as well as medications includingacetaminophen, nonsteroidal anti-inflammatory drugs,narcotics, steroids (oral or epidural), or muscle relaxantsare frequently prescribed in the acute phase. Theseagents decrease pain, inflammation, and/or musclespasm and thereby permit early and more rapid pro-gression of rehabilitation. Corsets are associated with asignificant potential for dependence and their useshould be gradually discontinued as soon as possible;however, patients with instability may benefit from con-trol of available lumbar range of motion and proprio-



ceptive feedback. Corsets also provide warmth to under-lying soft tissue and may decrease intradiskal pressure.

When formal rehabilitation begins, the physical ther-apist or other appropriate clinician should emphasizeeducation and protection of injured tissues, because thisis considered by many to be the most important compo-nent of a LBP program. Specific points should includepositions of comfort, proper sitting and standing ergo-nomics, and proper body mechanics for movement in-cluding position change, performance of ADLs (dress-ing, bathing, toileting, driving), and lifting. The clinicianalso may recommend that the patient avoid early morn-ing flexion, especially during the first hour after awak-ening, because of the increased fluid content and hydro-static pressures in the disk during that time. It has beenreported that in patients with chronic nonspecific LBPwho controlled early morning flexion for 6 months, dur-ing the first 6 hours of the day, pain intensity, total daysin pain, impairment and disability, and medication usagewere decreased. Passive techniques such as manual ther-apy (see chapter 14) and modalities may also play animportant role during the acute phase of rehabilitation.Although such passive treatments may facilitate a pa-tient’s progress, if used in a protracted manner theyplace the patient in a dependent role and become coun-terproductive to proceeding with participatory function-oriented and ultimately independent care.

ModalitiesModalities are physical agents used to produce a thera-peutic tissue response and to control pain and/or inflam-mation while the injury is given a period of relative rest.They are most effective when applied in response to aspecific diagnosis with close monitoring of the patient’sresponse. Commonly used modalities in the managementof LBP include cold, heat, and electricity. The physiologiceffects of cryotherapy include vasoconstriction with re-flexive vasodilatation and decreased local metabolism,enzymatic activity, and oxygen demand. Because it less-ens muscle spindle activity and slows nerve conductionvelocity, cryotherapy is often used to decrease musclespasticity and guarding to improve flexibility and func-tion. On the other hand, cold is associated with increasedconnective tissue stiffness and muscle viscosity. Indica-tions for cryotherapy in LBP include acute trauma,edema, hemorrhage, pain, and muscle spasm. Cold ispreferable to heat for acute spine injury (especially dur-ing the first 48 hours after injury) because it controlspain and spasm and also decreases inflammation. Tominimize the risk of developing neurapraxia, cold appli-cation should not exceed 30 minutes, and efforts shouldbe made to protect peripheral nerves in the region beingtreated. Contraindications to cryotherapy include is-chemia, Raynaud’s disease or phenomenon, cold intoler-ance, skin insensitivity, and inability to report pain.

Heat therapy is also commonly used in the setting ofLBP and includes both superficial heat and deep heat ordiathermy. In general, heat creates higher metabolic de-mand, which promotes increased capillary permeabilityas well as increased blood flow, bringing leukocytes andoxygen to tissue. Deep heat has also been shown to de-crease spasm and pain and increase collagen distensibil-ity, thereby improving flexibility. Indications for heat inthe treatement of LBP include pain, muscle spasm, anddecreased collagen extensibility. Contraindications toheat include inflammation, hemorrhage/bleeding disor-der, decreased sensation, poor thermal regulation, ma-lignancy, edema, ischemia, atrophic/scarred skin, and in-ability to respond to pain. Hydrocollator or heat packs,heating pads, and low-level heat wraps are typicallyused to provide superficial heat by warming tissue struc-tures via conduction, the transfer of heat directly fromone surface to another. Superficial heat typically pene-trates greatest at a 0.5- to 2.0-cm depth from the skinsurface, depending on the amount of adipose tissuepresent. Heat packs are heated in stainless steel contain-ers filled with 65° to 90°C water and then applied withtowels (to minimize skin trauma and maintain heat insu-lation) in treatment sessions lasting 20 to 30 minutes.One recent study found that continuous use of low-levelheat wrap therapy during sleep by patients with acutenonspecific LBP decreased pain throughout the nextday, reduced muscle stiffness and disability, and im-proved trunk flexibility; these effects were sustainedmore than 48 hours after treatment was completed.

Ultrasound is the most commonly used form of deepheat therapy and warms tissue via conversion, the trans-fer of heat via a change in energy. Such heat can pene-trate to depths of 5 cm below the skin surface, therebyproviding a therapeutic benefit to tendon, ligament,joint capsule, and even bone. Selective heating is great-est when the acoustic impedance is high, such as at thebone-muscle interface. Ultrasound is more typicallyused for subacute and chronic injuries; other indicationsfor its use in the treatment of LBP include associatedtendinopathy and degenerative arthritis. Ultrasound istypically used for periods of 5 to 10 minutes at inten-sities of 1.0 to 4.0 W/cm2. In addition to general heatprecautions, specific contraindications for ultrasound in-clude malignancy, open physeal growth plates, pacemak-ers, laminectomy sites, regions of acute disk herniationwith radiculopathy, fluid-containing cavities (for exam-ple, the uterus in a pregnant or menstruating woman,the testicle, or eye), unhealed fractures, joint arthroplas-ties containing methylmethacrylate or high-density poly-ethylene, and use near the brain.

Electricity is the third modality used in the treat-ment of LBP. Although transcutaneous electrical nervestimulation is the most commonly used form of thera-peutic electricity, other types include high-voltagepulsed galvanic stimulation, interferential electrical



stimulation, and minimal electrical noninvasive stimula-tion. Electricity acts physiologically to increase circula-tion and therefore aids in the removal of inflammatoryby-products; it has also been reported to decreaseedema, pain, spasm, inflammation, and muscle atrophy.Although typically indicated for chronic pain, transcuta-neous electrical nerve stimulation appears to have a rolein managing acute pain. Contraindications to electricityto treat LBP include active bleeding sites, cardiac pace-makers and defibrillators, areas with metal close to theskin, anesthetic areas, incompletely healed wounds, anduse near the eyes, carotid sinus, or mucous membranes.Cryotherapy, heat therapy, and therapeutic electricityhave all been shown to be helpful in relieving the painand/or inflammation associated with LBP; however,there is little proven benefit when these modalities areused in isolation. Therefore, modalities should be con-sidered an adjunctive treatment and included only aspart of a comprehensive rehabilitation program.

During the acute phase of rehabilitation, the clini-cian should also introduce the concept of neutral spineand determine the patient’s initial movement pattern.Neutral spine is an initial training posture, a loose-packed position that decreases tension on the ligamentsand joints and allows a more balanced segmental forcedistribution between the disk and facet joints. It is con-sidered to be the least painful and most biomechanicallysound position of power and balance. Because the neu-tral spine is close to the center of reaction, it providesgreater functional stability with axial loading and allowsfor quick movement into extension or flexion. The clini-cian should then instruct the patient in performing thefirst lumbar exercises, either in an extension or flexionbias based on the presumed lumbar pathology and re-sponse to repeated end-range movements. An extensionbias is most commonly used with discogenic pain wheresymptoms tend to decrease (or centralize) with repeti-tive extension on motion pattern testing. In this patientpopulation, extension exercises may reduce intradiskalpressure, allow anterior migration of the nucleus pulpo-sus, and increase mechanoreceptor input, thus activatingthe pain gate mechanism. Notably, this movement pat-tern may increase symptoms in patients with large cen-tral disk herniations, foraminal herniations, or foraminalstenosis. On the other hand, in the setting of facet jointpathology or spinal stenosis, a flexion bias is typically in-dicated because symptoms tend to decrease with repeti-tive flexion movements. Flexion exercises may reducefacet joint compressive forces and provide stretch to thelumbar muscles, ligaments, and myofascial structures;these exercises, however, may also increase intradiskalpressure and thus exacerbate discogenic pain.

Cardiovascular fitness should be initiated in refer-ence to the initial movement pattern. For example, if thedisk is the pain generator, aerobic activity that placesthe spine in a neutral to extension bias such as the

treadmill (0° incline) and the cross-country ski machineis typically indicated. Conversely, the stationary bicycleand inclined treadmill, machines that place the spine ina neutral to flexion bias, are usually recommended ifLBP originates from the facet joint or spinal stenosis.Although there is a limited amount of literature on thesubject, aquatic-based rehabilitation appears to be use-ful in the acute phase of rehabilitation because it allowsearly intervention of aerobic conditioning. Advantagesof aquatic rehabilitation include eliminating gravita-tional forces in a graded manner to allow training withcomfortable and adjustable axial loads; challenging ver-tical posture secondary to depth-dependent refractivealterations of proprioceptive cues; controlling velocitythrough water resistance, viscosity, buoyancy, and train-ing devices; increasing the range of training positions asthe result of buoyancy; and improving the margin of er-ror. Aquatic therapy has also been shown to attenuatepain because of hydrostatic pressure, temperature, andturbulence as well as enhance psychological outlook.Criteria for advancement to the next stage of rehabilita-tion include adequate pain control and tissue healingthat allows for normal or near-normal painless range ofmotion and initial strengthening of the injured tissues.

The Recovery Phase of RehabilitationThe recovery phase is the second and typically mostlengthy phase of a comprehensive rehabilitation pro-gram for LBP. During this stage, treatment emphasisshifts from resolution of clinical signs and symptoms torestoration of function. The goals of this stage are to re-gain local flexibility, proprioception, and strength at theinjured and adjacent motion segments of the lumbarspine. In addition, this focus should be applied to theentire kinetic chain because secondary biomechanicaldeficits exist at distant sites from the original injury as aresult of chronic overload before or as the result of in-jury. To achieve these objectives, the treatment emphasisin this stage of rehabilitation moves away from passivemodalities and manipulation and toward more focusedand aggressive active interventions. The focus is on corestrengthening. In general, the goals of this type of thera-peutic exercise are to improve core muscle activity andendurance; establish neuromuscular control of the coremuscles; restore coordination and position sense; in-crease lumbar mobility; train motor and postural controland balance; and to make exercises functional.

Specifically, the clinician leads the patient through aset of stabilization exercises. The reeducation of the coremusculature classically begins with exercises such as thecat and camel (flexing and extending the back in a quad-ruped position) and the pelvic clock (rotating the pelvisalong an imaginary ‘clock’ in a supine position with thefeet on the floor). These movements “turn on” pelvic andhip muscles and help achieve spinal segment and pelvic



accessory motion before more aggressive exercises areattempted. Improving hip range of motion also has beenshown to aid in dissipating forces from the lumbar spine.The patient then learns how to maintain the neutralspine in a static position, either supine or prone, whichhelps initiate awareness of motor patterns. Here, withverbal cues such as “bring the belly button back to thespine” or “squeeze the pelvic floor” and biofeedback, ifnecessary, the clinician facilitates activation of the coremuscles. Once these muscles are “awakened,” the exer-cises progress to functional positions such as sitting andstanding and then dynamic activities such as walking,running, and even jumping. In addition, because func-tional activities move through the neutral position, theexercises are advanced to nonneutral positions. Finally,graded challenges to the neutral spine are created, first

by gravity, and then by the therapist or an assistive de-vice such as the physioball; these challenges shouldprogress from the predictable to the unpredictable.

Activity-specific retraining is then directed based onADLs and the patient’s unique functional activities.Each required motion is broken down into its individualcomponents with the neutral spine trained for each; theparts are then reassembled so that the entire motionuses dynamic stabilization techniques. Finally, if the pa-tient participates regularly in any sports activities, spe-cific training should be included in this set of exercises.Because sports movement occurs in all three cardinalplanes, the core should be trained in each of these direc-tions (Figures 1 through 4). Additionally, because pro-prioception and balance are vital to the performance ofsports, exercises should progress to labile surfaces. Atthe conclusion of this core strengthening program, thepatient should have learned how to recruit spinal mus-cle stabilizers quickly and automatically, thereby con-trolling pain, optimizing soft-tissue repair and degenera-tion, gaining dynamic control of the segmental spineand kinetic chain forces, eliminating repetitive motionsegment injury, and minimizing the chance of acute dy-namic overload.

Other components of the recovery phase of rehabili-tation include flexibility and strength programs and car-diovascular training. Flexibility exercises aim to correctmuscle tightness, and allow the patient to assume a neu-tral position so that strength can be developed to helpmaintain correct neutral positioning during both staticand dynamic conditions. Muscular weaknesses and im-balances, total body strength, endurance, and power,specific to the demands of the patient’s specific actions,are addressed in the strength program. Cardiovasculartraining helps provide the necessary aerobic and anaer-obic fitness required for activities; when performed in aneutral spine position, such training helps maintain fit-

Figure 2 A and B, Core strengthening exercise in the frontal plane.

Figure 1 A through D, Core strengthening exercise in the sagittal plane.



ness while protecting the lumbar spine. Criteria for ad-vancement to the third stage of rehabilitation includecomplete pain control and tissue healing with essentiallyfull painless range of motion and good flexibility. Theathlete should be able to demonstrate strength of ap-proximately 75% to 80% or greater compared with theuninjured side; there should also be good strength bal-ance.

The Maintenance Phase of RehabilitationThe final stage of a comprehensive rehabilitation pro-gram for LBP is the maintenance phase, which formsthe basis for the prevention program. The goals of thisstage of rehabilitation are to resolve the patient’s resid-ual biomechanical deficits and any subclinical adapta-tions (the substitute motions and/or activities used tocompensate for an injury and its associated mechanicalproblems). This phase is devised as the patient returnsto work or sport-specific activity to promote continuedcardiovascular fitness and moreover, prevent reinjury.Specific components of the maintenance phase includeeducation about ergonomics, equipment, and assistivedevices; eccentric muscular strengthening with work andsport-specific training if applicable; power and endur-ance exercise; and progression to an independent homeexercise program. The patient should also be equippedwith the appropriate knowledge to solve problems thatoccur after discharge from physical therapy. Completionof a rehabilitation program for LBP is indicated by ab-sence of signs and symptoms of the original injury, fullpain-free range of motion, normal flexibility, normalstrength and strength balance, good general fitness, nor-mal mechanics for work or sport, and the ability to per-form job and sport-specific skills. Rehabilitation mustprogress beyond the absence of symptoms. Because sta-tistics show that 70% to 90% of patients with LBP haverecurrent episodes, the absence of symptoms does not

necessarily imply normal function. By seeking to resolvethe anatomic and functional changes associated withLBP, a comprehensive rehabilitation program may helpreduce the incidence of LBP and its related impair-ments, disabilities, and high treatment costs.

Annotated Bibliography

Akuthota V, Nadler SF: Core strengthening. Arch PhysMed Rehabil 2004;85(suppl 1):S86-S92.

This review article uses a theoretic framework to describethe available literature on core strengthening in the rehabilita-tion of patients with LBP.

Fritz JM, Delitto A, Erhard RE: Comparison ofclassification-based physical therapy with therapy basedon clinical practice guidelines for patients with acutelow back pain: A randomized clinical trial. Spine 2003;28:1363-1371.

Figure 4 Core strengthening exercise in the frontal plane with labile surface.

Figure 3 A through D, Core strengthening exercise in the transverse plane.



In this study, the effectiveness and medical costs of aclassification-based approach to the rehabilitation of patientswith acute LBP was compared with an approach based on theAgency for Health Care Policy Research guideline, which indi-cates a more general approach for the first 4 weeks of rehabil-itation. The findings of this study demonstrate thatclassification-based treatment results in significantly betteroutcomes for disability (up to 1 year), return to work, and pa-tient satisfaction at 4 weeks compared with the resultsachieved in the guideline-based group; there was also a trendtoward less cost with the more specific treatment regimen.

Hides JA, Jull GA, Richardson CA: Long-term effectsof specific stabilizing exercises for first-episode low backpain. Spine 2001;26:E243-E248.

LBP patients were randomly allocated to a control groupreceiving advice and medications or a specific exercise groupperforming core strengthening exercises targeting the multifi-dus in co-contraction with the transversus abdominis. The corestrengthening group had fewer recurrences of LBP comparedwith the nonexercise group at 1 year (30% versus 84%) and at2- to 3-year follow-up (35% versus 75%).

Kavcic N, Grenier S, McGill SM: Determining the stabi-lizing role of individual torso muscles during rehabilita-tion exercises. Spine 2004;29:1254-1265.

The potential stabilizing role of individual lumbar muscleswas evaluated through a systematic biomechanical analysis in-volving an artificial perturbation. Findings suggested that nosingle muscle dominated in the enhancement of spine stability,and the muscles’ individual roles were continuously changingacross tasks. Therefore, it was proposed that global muscle ac-tivation by co-contraction of multiple agonist/antagonist mus-cles was preferable to training primarily “local” muscles.

Long A, Donelson R, Fung T: Does it matter which ex-ercise?: A randomized control trial of exercise for lowback pain. Spine 2004;29:2593-2602.

In a multicenter, randomized controlled trial of 312 pa-tients with acute or chronic LBP or sciatica with or withoutneurologic findings, the authors used a standardized mechani-cal assessment to identify two groups based on the presence orabsence of a directional preference. The 230 patients that ex-hibited a lasting beneficial pain response to one particularmovement were then randomized to one of three exercisetreatments including directional exercises “matching” the di-rectional preference, exercises directionally “opposite” to thedirectional preference, and nondirectional exercise. Althoughall three exercise treatment groups showed improvement in alloutcomes including pain intensity and medication usage, therewere significantly greater improvements in every outcome inthe exercise-matched group compared with the other treat-ment groups.

Nadler SF, Malanga GA, DePrince M, et al: The rela-tionship between lower extremity injury, low back pain,

and hip muscle strength in male and female collegiateathletes. Clin J Sport Med 2000;10:89-97.

In this cohort study of college athletes, a significant differ-ence in side-to-side symmetry of maximum hip extensionstrength was observed in female athletes who reported lowerextremity injury or LBP as compared with those who did not.Side-to-side difference in hip strength, however, did not differbetween male athletes, regardless of reported lower extremityinjury or LBP status. Female athletes appear to have a differ-ing response of the proximal hip musculature to lower extrem-ity injury or LBP, compared with their male counterparts.

Nadler SF, Steiner DJ, Petty SR, et al: Overnight use ofcontinuous low-level heatwrap therapy for relief of lowback pain. Arch Phys Med Rehabil 2003;84:335-342.

This study found that 8 hours of continuous low-level heatwrap therapy used during sleep by patients with acute nonspe-cific LBP decreased pain throughout the next day, reducedmuscle stiffness and disability, and improved trunk flexibility.These effects were sustained more than 48 hours after treat-ment was completed. Adverse events were mild and infre-quent.

Panjabi MM: Clinical spinal instability and low backpain. J Electromyogr Kinesiol 2003;13:371-379.

This article describes the stabilizing system of the spinewhich includes the spinal column, spinal muscles, and neuralcontrol unit. A hypothesis relating the neutral zone to pain isexplained and in vitro experiments and mathematical modelsshowing spinal muscles providing significant stability to thespine are presented. Increased body sway was found in pa-tients with LBP, indicating a less efficient neuromuscular con-trol system with decreased ability to provide the needed spinalstability.

Vad VB, Bhat AL, Basrai D, et al: Low back pain in pro-fessional golfers: The role of associated hip and lowback range-of-motion deficits. Am J Sports Med 2004;32:494-497.

In this study, 42 professional golfers were categorized intogroup 1 (history of low back pain for more than 2 weeks thataffected quality of play) and group 2 (no previous history ofpain). A statistically significant correlation (P < .05) was ob-served between the group with a history of low back pain withdecreased lead hip internal rotation, Fabere’s distance, andlumbar extension.

Classic Bibliography

Cholewicki J, McGill SM: Mechanical stability of the invivo lumbar spine: Implications for injury and chroniclow back pain. Clin Biomech (Bristol, Avon) 1996;11:1-15.

Delitto A, Cibulka MT, Erhard RE, et al: Evidence foruse of an extension-mobilization category in acute low



back syndrome: A prescriptive validation pilot study.Phys Ther 1993;73:216-222.

Deyo RA, Diehl AK, Rosenthal M, et al: How manydays of bed rest for acute low back pain?: A randomizedclinical trial. N Engl J Med 1986;315:1064-1070.

Donelson R, Silva G, Murphy K: Centralization phe-nomenon: Its usefulness in evaluating and treating re-ferred pain. Spine 1990;15:211-213.

Hides JA, Stokes MJ, Saide M, et al: Evidence of lumbarmultifidus muscle wasting ipsilateral to symptoms in pa-tients with acute/subacute low back pain. Spine 1994;19:165-172.

Hodges PW, Richardson CA: Inefficient muscular stabi-lization of the lumbar spine associated with low backpain: A motor control evaluation of transversus abdomi-nis. Spine 1996;21:2640-2650.

McGill SM: Low back exercises: Evidence for improvingexercise regimens. PhysTher 1998;78:754-765.

Press JM, Livingston BP: The effective use of rehabilita-tion modalities, in Kibler WB, Herring SA, Press JM

(eds): Functional Rehabilitation of Sports and Muscu-loskeletal Injuries. Gaithersburg, MD, Aspen Publishers,1998.

O’Sullivan PB, Phyty GD, Twomey LT, et al: Evaluationof specific stabilizing exercise in the treatment ofchronic low back pain with radiologic diagnosis ofspondylolysis or spondylolisthesis. Spine 1997;22:2959-2967.

Saal JA, Saal JS: Nonoperative treatment of herniatedlumbar intervertebral disc with radiculopathy: An out-come study. Spine 1989;14:431-437.

Snook SH, Webster BS, McGorry RW, et al: The reduc-tion of chronic nonspecific low back pain through thecontrol of early morning lumbar flexion: A randomizedcontrolled trial. Spine 1998;23:2601-2607.

Stankovic R, Johnell O: Conservative treatment of acutelow-back pain: A prospective randomized trial: McKen-zie method of treatment versus patient education in“mini back school”. Spine 1990;15:120-123.



The Management of Low Back Pain: A Comprehensive ... · Low back pain (LBP) is a ubiquitous...

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