Conquering the Complex

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August 2004

By Jennifer B. Green, MSPT; Laura E. Kelly, PT, MA; and R. Derek Munn, MPT

Thirty million Americans are presently dealing with a low back injury. Eighty percent of adults will experience low back pain sometime in their lives. Low back injury is the number two reason for primary care physician visits after the common cold. The cost in medical expenses and lost productivity for low back injury is in excess of $60 billion annually. In a managed care environment, the health care professional is responsible for delivering quality care that not only restores function but also is cost-effective.

People seeking relief of back pain are flooded with remedies offered by health care professionals and nonmedical individuals. As experts in the field of movement sciences, physical therapists uniquely offer the skills to fully address the complex nature of low back injury. The PT uses a multi-modal treatment approach to address the multiple systems affected in low back injury. Using sound clinical reasoning to rehabilitate the client with a low back injury is achieved by integrating the current evidence with the PT's experience.

A rehabilitation manager may oversee a physical therapy staff trained in various techniques and approaches. The manager can ensure that each client achieves the best possible outcome by fostering an environment that supports a diversely trained staff. Utilizing in-service education, mentoring, and peer review programs provides clinicians with tools to continually improve their clinical reasoning skills. Outcome measures and evidence-based practice assist clinicians in refining their treatment strategies to reflect new information about the treatment of low back injury.

UNDERSTANDING INJURY
Clients who come to the clinic with a diagnosis of low back injury are a diverse group that includes industrial workers, multi-level athletes, office workers, and the elderly. While the history of their injuries may be very different, there are commonalties in the mechanisms of injury. Despite the technologic improvements in diagnostic imaging of the low back, the tissues that are responsible for a client's pain cannot always be identified. Understanding the factors present at the time of injury provides useful information for determining the direction of the rehabilitation intervention.¹

Clients who report insidious onset of pain or low back injury from minimal loads to the spine often have underlying chronic changes that complicate their presentation. Aging and sedentary lifestyles are the hallmarks of these changes associated with deconditioning and degeneration of the spine. The term "self-injury" has been used to describe back dysfunction associated with a sedentary lifestyle.² These clients present a challenge in designing a treatment strategy because the range available for optimal loading of the low back tissues through activity and exercise is reduced from the injury to the tissues and from the effects of the aging process and a sedentary lifestyle. Addressing the effects of the degenerative processes is the key to prevention of reinjury in this population.³ A single application of a high load to the spine or physical trauma results in more acute injury to the low back. These clients may not present with the long-standing degenerative problems of the first group. Treatment intervention can be directed to the focal damage that occurs with this type of injury.

The client with low back injury can present with dysfunction in any of the three back systems: the osseoligamentous, the muscular, and the neural systems. Thorough assessment of all three systems is necessary to successfully help the client manage pain, restore function, and prevent recurrence of low back injury. The most intimate of structures in the back is the spinal column, which, in times of injury, can lose functional integrity resulting in pain from overstressed structures. Disruptions to the intervertebral joint, the disc, or facet joint can result in malalignment of a spinal segment and are believed to be a potential pain source.^4-6

A number of treatment approaches exist aimed at correcting segmental disruptions and the resulting impairments in motion. The use of manipulation, a high-velocity passive movement of the vertebral segments to end range positions, decreases malalignments, frees bound structures, and reduces pain through endorphin release.⁴ Spinal manipulation has a substantial amount of evidence supporting its effectiveness for treating low back injury.⁷ More recent evidence exists that identifies the specific characteristics of clients who would most likely benefit from manipulation.⁸

Mobilization treatment, using amplitudes of movement less than the full available range, can reduce pain by stimulating mechanoreceptors and improving proprioception.⁹ Larger amplitudes of movement can decrease joint restrictions, allowing for more normal joint motion and less stress. Reducing stiffness in segments surrounding hypermobile regions of the spine directs the stressful forces away from these problematic areas to allow for healing.

McKenzie's approach of using repeated movements of the spine to end range positions offers benefits shared by both of these prior techniques. There is evidence that suggests using repeated movements to reduce derangements from disc disruptions.¹⁰ The nucleus of the intervertebral disc may become displaced with injury and can either become the pain source or cause pressure on sensitive structures. The disc may be able to assume its original form and eliminate pain with repeated movements.

The muscular system helps to compensate for the structures affected in low back injury, whether that injury occurs because of lesions in the disc, from degenerative bony changes, or from soft tissue injury. The muscles have the potential to respond to training and to facilitate a return of normal function. Muscles have a quicker response to tissue repair than the disc or ligamentous tissue.¹¹

Recent research advances enhance the clinician's ability to design and implement an effective, graded exercise program that aids the healing process in the early stages of low back injury and provides the basis for successfully decreasing recurrence. The use of low resistance and high repetitions in exercise prescription creates an environment that supports tissue healing and introduces appropriate forces into the tissues. Functional healing of the low back occurs with varying positions of exercise that minimize the load on the spinal tissues.^1,3,11-13

Exercise programs aimed at preventing recurrence of low back injury need to emphasize strength and endurance of all the muscles that act on the lumbopelvic region rather than concentrating on individual muscles.¹² Multiple exercises in different positions must be used to recruit both the single-segment and multi-segment muscles that control the trunk. Good motor control of the lumbopelvic musculature is necessary for effective co-contraction in stabilizing the lumbar spine.

McGill et al showed that the spine could buckle at a single level when the passive range is exceeded during activity.¹³ McGill, Richardson, and others have worked to understand this mechanism of low back injury. They have found that maintaining a neutral spine with appropriate muscle bracing of the abdominal and torso muscles can prevent this buckling in multiple positions and with applied loads, thus reducing the risk for low back injury.^12-14

Impairment in muscle tissue can also be implicated in back injury.¹⁵ Acute muscle strain, chronic overuse injury, spasm, tightness, and myofascial dysfunction are all conditions that can result in pain. PTs evaluate the incriminating tissues using procedures such as muscle length testing, palpation, repeated end range movements, and provocation testing.

DETERMINING PAIN LEVEL
These test findings in combination with an accurate client history direct the appropriate treatment strategy by identifying how acute the injury is. Dysfunction in the muscles can be addressed with stretching and soft tissue mobilization. Modalities may be used in conjunction with these techniques for treating more acute symptoms.

The muscles of the lower extremities need to be assessed in the low back injury client because shortening of these muscles is known to inhibit normal excursion and motor control of the lumbar spine and pelvis. Developing and maintaining good flexibility of the hip and knee muscles are also important for reinjury prevention.¹

Integrating the current research on exercise for low back injury will assist in designing appropriate exercise programs and postural strategies to restore function and prevent the recurrence of pain.

The importance of assessing neural structures is often overlooked in the clinical examination and in the development of the treatment program. The neural system can be compromised by compression or inflammation of the nerve root due to swelling of the nerve and surrounding tissues.¹⁶ Clinically, the client presents with restricted or antalgic movement patterns that affect normal daily function.

Neurological screening can help in determining a physical therapy diagnosis and in assessing the severity and irritability of the symptoms. Changes in myotome testing, deep tendon reflexes, and sensory testing may indicate a nerve root lesion or other irritable neural structures.

Dural and nerve mobility testing is useful in identifying the postures and positions that are affecting the client's symptom levels. Seated slump and straight leg raise testing that reproduces the client's symptoms implicates the neural tissue as a possible source of pain.¹⁷

The treatment of neural structures can be performed in multiple ways. Neural gliding techniques decrease inflammation of the neural tissue through direct treatment.¹⁶ Indirect treatment involves educating the client on how to change daily habits to control for factors that are aggravating the pain symptoms. Assessing the postures and positions that directly affect tissue irritability is imperative. Learning which positions increase and decrease pain symptoms allows the client to control these aggravating factors.

Gaining control of the pain symptoms early in the rehabilitation process allows the client to progress more rapidly toward regaining normal function. Appropriate assessment of the osseoligamentous, the muscular, and the neural systems is necessary to understand the behavior of the client's symptoms. The clinician uses this information to educate the client on how to move within safe and pain-free postures. Through proper positioning and motor control of the spine, the client learns important strategies for self-management during the acute episode and for prevention of reinjury.

CONCLUSIONS
Low back injury affects a large percent of society today at a substantial cost. PTs are increasingly more valuable with their unique understanding that enables them to address the complexity of problems associated with low back injury. A clinical environment promoting understanding and development of clinical reasoning skills can maximize clients' outcomes.

Jennifer B. Green, MSPT, Laura E. Kelly, PT, MA, and R. Derek Munn, MPT, are physical therapists at Spaulding Rehabilitation Hospital in Framingham, Mass.

REFERENCES

McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther. 1998;78:754-765.
Garner-Morse M, Stokes IAF, Laible JP. Role of muscles in lumbar spine stability in maximum extension efforts. J Orthop Res. 1995;13:802-808.
Porterfield J, DeRosa C. Mechanical Low Back Pain. 2nd ed. Philadelphia: WB Saunders; 1998:1-22.
Basmajian JV, Nyberg R. Rational Manual Therapies. Baltimore: Williams and Wilkins; 1993.
Cavanaugh JM, Ozaktay CA, Yamashita HT, King AI. Lumbar facet pain: biomechanics, neuroanatomy, and neurophysiology. J Biomech. 29;9:1117-1129.
Grigg P. Articular neurophysiology. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia: WB Saunders; 1996:152-169.
Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 2004;29:1254-1265.
Childs JD, Fritz JM, Piva SR, Ehrard RE. Clinical decision making in identification of patients likely to benefit from spinal manipulation: a traditional versus evidence-based approach. J Orthop Sports Phys Ther. 2003;33:259-271.
Maitland GD. Vertebral Manipulation. 3rd ed. London: Butterworths; 1973.
McKenzie RA, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. Vol 2. Minneapolis: Orthopedic Physical Therapy Products; 2003.
Richardson CA, Jull GA. An historical perspective on the development of techniques to evaluate and treat the active stabilizing system of the lumbar spine. Australian Journal of Physiotherapy Monograph. 1995;1:5-13.
McGill SM. Linking the latest knowledge of injury mechanisms and spine function to the prevention of low back disorders. J Electromyogr Kinesiol. 2004;14:43-47.
Cholewicki J, McGill SM. Lumbar posterior ligament involvement during extremity heavy lifts estimated from fluoroscopic measurements. J Biomech. 1992;25:17-28.
Richardson CA, Jull GA, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. London: Churchill Livingstone; 1999.
Simons DG. Muscle pain syndromes. Journal of Manual Medicine. 1991;6:3-23.
Grieve G. Grieve's Modern Manual Therapy. London: Churchill Livingstone: 1986.
Saunders HD, Saunders R. Evaluation, Treatment and Prevention of Musculoskeletal Disorders. Vol 1. 3rd ed. Chaska, Minn: Saunders Group; 1995.

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August 2004