Carl P DeRosa and James A Porterfield 1992; 72:261-269. PHYS THER.

Transcription

A Physical Therapy Model for the Treatment of Low
Back Pain
Carl P DeRosa and James A Porterfield
PHYS THER. 1992; 72:261-269.
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Clinical Perspective
Back Pain
Carl P DeRosa
James A Porterfleld
Low back pain is commonly seen in physical therapy practice, and many methods
of treatment are used to reduce it. In this article, we d k c m the magnitude of the
low back pain problem, outline the various treatment methods, and develop a
strategy to classaJi, and standardize the treatment of the patient who has low back
pain. Wle will develop this thought process by discming$ve management consideration~(I) the dilemma of diagnosis, (2) the information gainedfrom the messment, (?) a patient classa$cation system, (4) the objectives of the low back treatment process, and (5)a proposed physical therapy intervention model that
matches the objectives of treatment to the classa$cation of the patient. [DeRosa CP,
Porterjield JA. A physical therapy model for the treatment of low back pain. Phys
Ther. I!292; 72:26I-272.1
Key Words: Diagnosis, Low back pain, Low back rehabilitation, Model, Treatment.
Low back pain continues to be one of
the most prevalent problems in health
care today. In many orthopedic physical therapy clinics, patients with low
back pain constitute the majority of
patients seen for evaluation and treatment. Not only is low back pain one
of the rnost common musculoskeletal
problerns in industrialized societies,
but it is also the most costly, and it is
the prirnary cause of disability in persons under age 45 years.'" The magnitude of the economic burden has
been estimated at $40 to $50 billion
annually, which includes medical,
compensation, legal, vocational retraining:, and lost productivity costs.5
Disordr:rs of the low back have truly
reached epidemic proportions. This
article explores the epidemiology of
the problem, presents evaluation and
treatment issues that the clinician
needs to address, and proposes a system to standardize the classification
and treatments of low back disorders.
In 1987, at the request of the Quebec
Workers' Health and Safety Commission, the Quebec Task Force on Spinal Disorders (QTFSD) published a
monograph that provided a comprehensive examination of the scientific
evidence for the assessment and management of activity-related spinal disorders, those disorders typically
caused o r exacerbated by movement
on postural positions that excessively
load the spinal tissues.' This report
CP DeRo.sa, PT, is Associate Professor and Chairman, Physical Therapy Program, Northern Arizona
University, Box 15105, Flagstaff, A2 86011 (USA).Address correspondence to Mr DeRosa.
JA Porterfield, PT, ATC, is President, Rehabilitation and Health Center Inc, Crystal Clinic, 3975 Embassy Phcry, Ste 108, Akron, OH 44333, and Assistant Professor of Physical Therapy, Cleveland State
University, Cleveland, OH 44115.
was commissioned because of the
increase in physical therapy interventions for low back disorders in Quebec, Canada. Furthermore, the Quebec Workers' Health and Safety
Commission was particularly concerned with the wide variation in
types and duration of treatment from
one institution to another.
The great diversity of assessment and
treatment approaches is well recognized by most physical therapists. The
proliferation of continuing education
courses on evaluation and treatment
of low back disorders indicates that
there are many different schools of
thought. The instructors responsible
for orthopedic courses in physical
therapy curricula often struggle to
introduce the student to a variety of
assessment and treatment approaches,
es
even if the various a ~ ~ r o a c hconfliCtwith one another or lack a scientific basis. This diversification of assessment and treatment approaches
has occurred simultaneously with the
development of new knowledge
..
This article was submitted April 16, 1992, and was accepted November 6, 1991.
Physical TherapyNolume 72, Number 4/April 1992
261 /21
about the anatomy and biomechanics
of the spines15 and remarkable advances in technology (eg, magnetic
resonance imaging, computer assisted
tomography) that allow visualization
of the low back not previously
thought possible.
of spine disorders, encouraged his
physician colleagues to consider reappraising their traditional approach
toward low back problems. His messages were many. Following are a few
of his questions and comments that
especially deserve our attention:
In the decade from 1971 to 1981, the
number of individuals disabled from
low back pain grew at a rate 14 times
that of the population growth.6
Mooney16 points out that this growth
also occurred in the same decade in
which there was a rapid expansion of
ergonomic knowledge, labor-saving
mechanical assistance devices, and
improved diagnostic equipment.
1. Is the approach toward low back
disorders actually the major problem? Waddell19 points out that low
back pain is a benign, self-limiting
condition that is so common it
could almost be interpreted as a
normal occurrence.
Advances in evaluation and treatment
methodologies and increased understanding of the pathological process
usually lead to a decrease in the incidence of health problems and to improvement in the effectiveness of intervention~.'~
The opposite seems to
be the case with low back disordersas our understanding increases, the
problems appear to multiply. The
proliferation of new technology and
advanced clinical skills for the assessment and treatment of spinal pain has
not influenced the overall incidence,
morbidity, cost, o r disability related to
spinal pain disorders.17
One might also argue that a more liberal definition of the term "disabled
low back" is also to blame. Perhaps
the standard for disability has changed
over time and patients have perfected
their ability to use the "system." This
compounds the problem facing clinicians, because they are then faced with
an additional, albeit unwelcome, responsibility4eciding that patients are
not indicated for treatment because of
a perception, often lacking objective
measures, that the system is being manipulated. Psychological factors are
known to have a great influence on
the patient's perception of low back
pain, and a patient's psyche has an
important effect on the outcome of
physical treatment.l8
In 1987, Waddel1,lg who was awarded
the prestigious Volvo Award for outstanding work in the clinical science
2. Are current methods of intervention appropriate for a disorder that
in reality might be considered a
fact of life, and does a passive approach toward treatment propagate
the problem?
the meaning and consequences of the
pain, but acute pain, acute disability,
and acute illness behavior are generally proponionate to the physical findings. . . . In contrast, chronic pain,
chronic disability, and chronic illness
behavior become increasingly dissociated from their original physical basis,
and there may indeed be little objective evidence of any remaining nociceptive stimulus. Instead, chronic pain and
disability become increasingly associated with emotional distress, depression, failed treatment, and adoption of
a sick role. Chronic pain progressively
becomes a self-sustaining condition
that is resistant to traditional medical
management. Physical treatment directed to a supposed but unidentified
and possibly nonexistent nociceptive
source is not only understandably unsuccessful but failed treatment may
both reinforce and aggravate pain,
distress, disability, and illness
behavior.l9@636)
3. What determines the plan of treatment? According to Waddell, once
a patient reaches a physician,
. . . medical assessment and treatment
is influenced more by the patient's distress and illness behavior than by the
actual physical disorder. Medical treatment may in theory be prescribed for
physical indications, but in practice
both conservative and surgical treatment for a poorly understood condition such as low back pain is determined to a much greater extent than
most physicians realize, or would like
to admit, by the patient's distress and
illness behavior.l9@635)
Although Waddell is addressing physicians, physical therapists should be
able to recognize this same dilemma.
4. Should we treat the patient who
has acute pain and the patient who
has chronic pain in the same manner? Waddell19 states that chronic
pain is different from acute pain
and that we have perhaps failed to
completely understand the ramifications of this important difference.
He further notes that
. . . acute and chronic pain are not only
different in time scale but are fundamentally different in kind. Acute pain
bears a relatively straightforward relationship to peripheral stimulus, nociception, and tissue damage. There may
be some understandable anxiety about
Clinicians who treat patients who
have low back disorders should recognize this distinction.
The enormous cost of low back pain
is not evenly distributed among all
patients. Only 10% of the patients are
responsible for 80% of the costs.5 In
order to effectively address the problem, therapists must at least be able to
differentiate between acutely injured
patients and those with chronic pain
syndrome.
Waddell's observations19 should encourage the physical therapist to scrutinize the physical therapy management of the patient with low back
pain. We believe that failure to recognize the natural history of low back
pain and the utilization of inappropriate treatments may result in conversion of simple low back pain into low
back disability. Therefore, before initiating therapeutic interventions with
the patient who has low back pain,
the clinician must be able to recognize the difference between low back
pain and low back disability.
Assuming a sick role may result in
secondary gain for some patients, and
this must be addressed by the therapist. Whereas our hard questions in
the past have been related to types of
Physical Therapy/Volume 72, Number 4/April 1992
t
I
b.
treatment, the harder question in the
future may be deciding who needs
physical therapy.
In an attempt to organize our
thoughts about a comprehensive
physical therapy strategy to deal with
this complex problem, we will address the following five topics: (1) the
dilemma of diagnosis, (2) the information gained from the assessment,
(3) a patient classification system,
(4) the objectives of the treatment
process, and (5) a proposed physical
therapy intervention model that
matches the objectives of treatment to
the clarssification of the patient. Where
appropriate, we have proposed an
action plan that we feel directly places
the physical therapist in a position to
be one of the health care professionals helping to curtail the epidemic
nature of the problem.
The Dllemma of Diagnosis
The precise diagnosis is unknown in
80% to 90% of patients with low back
pain.Z0 Nachemsonzl has estimated
that only 15% of patients experiencing low back pain for longer than
3 months have some demonstrated
patho-anatomic explanation for their
symptoms. We believe, however, that
clinicians are a lot like patients: both
dislike uncertainty. A basic human
drive is to search for meaning as the
first stage to control.l9 Even though
neither the pathologic basis of low
back pain nor the anatomic source of
the pain have been identified, clinicians often feel compelled to give a
diagnosis.
The dilemma of uncertainty appears
to be avoided for both the patient and
the clinician when a diagnosis is
made. According to Waddel1,lg patients and clinicians alike are much
happier with even a nominal diagnosis. We tend to forget, however, that
often this nominal diagnosis is only a
convenient pathophysiologic hypothesis based on examiner bias.
We are cognizant of the arguments
for o&:ring a precise diagnosis. The
basis of the patient's confidence rests
in the practitioner's ability to make
the patient believe the practitioner
knows what is wrong. We believe the
potential exists for a "vague" diagnosis to yield a "vague" treatment approach, which in turn might yield a
"vague" patient response. Conversely,
we believe that an "exact" diagnosis
based on biomechanics, which may
not even be scientifically "proven," is
perhaps beneficial simply because it
makes good sense to the clinician and
the patient. The benefit is that a more
positive environment for treatment
ensues, and the patient is not left with
the sense that "no one knows what is
wrong with me."
determining the mechanical stress or
combination of stresses that provoke
the familiar symptoms.
There are a myriad of assessment
techniques for low back pain syndromes. Some physical examination
methods have been shown to yield
reasonably reliable measurem e n t ~ . What
~ ~ 3has
~ not been shown,
however, is whether these reliable
measures are valid and whether they
are predictors of treatment resp~nse.~O
Segmental hypomobility,
hypermobility, facet syndrome, sacroiliac dysfunction, muscle imbalance,
and disk derangement have yet to be
shown in any randomized controlled
studies to relate to the incidence or
severity of low back pain. Just as various imaging techniques have revealed
deviations from a perceived norm in
asymptomatic individuals,27 we must
acknowledge that many measures
used by physical therapists have the
same shortcoming.
This perspective, however, has resulted in treatment strategies designed around pathophysiologic hypotheses related to dysfunction of
~ ~ -example,
~5
particular t i s s ~ e s . l 5 ~ For
therapeutic intervention is often
based on the disk model, following
the work of Mixter and BarrZ2and
Cyriax23;the joint model developed in
osteopathy and by MaitlandZ4;and the
myofascial syndromes.25
These models, which ultimately dictate methods of treatment, are based
on the pathology of specific tissues.
But are such models adequate for the
diagnosis of activity-related spinal disorders?7 Diagnosing activity-related
spinal disorders requires assessment
of the biomechanics of the mechanism of injury and the determination
of the type of forces and positions
that reproduce the familiar symptoms.
Tissue-related diagnoses are usually
based on radiographic or other imaging findings, or on pathophysiologic
hypotheses. At least 30% of asymptomatic individuals, however, show abnormalities in the lumbar spine, as
determined by the use of myelographs, computed tomographic scans,
and magnetic resonance imaging
scans.19,26,27
We believe that, at present, identifylng
with any certainty the exact tissues
involved in most low back pain is
virtually impossible. We suggest that,
in the case of activity-related spinal
disorders, the physical therapist's focus should not be on identifylng the
tissues that are at fault, but rather on
Consider for example the finding of
joint hypomobility. Three of the many
possible explanations for this finding
might be
1. Hypermobility of one segment
leads to excessive stresses being
placed on neighboring joints, rendering them injured, fibrosed, or
dysfunctional.
2. Adaptive shortening of a joint capsule causes decreased mobility.
3. Muscle imbalance results in movement disorders, creating excessive
force at one joint and causing decreased function.
These explanations all have individual
merit. The problem, however, of relating these descriptions of hypomobility with back pain rests with developing an accurate reproducible
measurement and the recognition of
the fact that most asymptomatic individuals have asymmetrical facets of
the lumbar spine that may or may not
create asymmetrical movement patterns.33 Although segmental hypomobility may be determined by an examiner, its relationship to the current
episode of low back pain cannot be
substantiated.
The dilemma of diagnosis for activityrelated low back disorders is complicated even further because patients
with low back pain often receive many
different diagnoses over time.7 In our
experience, it is common for many
patients with low back pain to anive in
clinics with three or more previous
ditferent diagnoses, each, we believe,
representing examiner bias. Patients'
back problems have been given such
labels as "ruptured disk," "trigger
points," "ligament sprain," "muscle
tear," "bone out of place," "pinched
nerve," and "sacroiliac torsion." Such
wide variability in terminology and
diagnoses makes it virtually impossible
to measure the success of low back
pain management programs and presumably adds to patient frustration.
Having multiple ditferent diagnoses,
the patient begins to conclude that
perhaps something is seriously wrong
to warrant such diversity.
Terms such as "disk disease" and "facet joint syndrome," in most instances,
are ambiguous because it is dificult to
measure these phenomena or to
clearly define their contribution to
pain in a given patient. Instead, terms
such as "low back pain" and "low back
pain with referral into the leg" are
more well defined and unambiguous.
The QTFSD clearly recognized this
dilemma of diagnosis. They recommended only 11 classifications of
activity-related spinal disorders.7 The
categories are listed in Table 1.
The QTFSD classification scheme
might be useful to physical therapists
because it recognizes that, in most
instances, naming anatomical structures is nonproductive. We believe a
modified version of the QTFSD's categories make them relevant to a
scheme for physical therapy diagnosis
(Tab. 2).
One compelling reason for the development of a physical therapy classification scheme is that a universally
- Table 1. Quebec Task Force o n
Spinal Disorders Classzjication System
Table 2. Modijed Physical nerapy
Diagnosis CIassijcationa
Category Detlnltlon
Category DeflnRlon
Pain without radiation
1
Back pain without radiation
Pain with radiation to extremity,
proximally
2
Back pain with referral to
extremity, proximally
Pain with radiation to extremity,
distally
3
Back pain with referral to
extremity, distally
Pain with radiation and
neurologic signs
4
Extremity pain greater than
back pain
Presumptive compression of a
spinal nerve root on a simple
roentgenogram (ie, spinal
instability or fracture)
5
Back pain with radiation and
neurological signs
6
Postsurgical status (<6 months
or 2 6 months)
7
Chronic pain syndrome
Compression of a spinal nerve
root confirmed by specific
imaging techniques (ie,
computer assisted
tomography, myelography,
magnetic resonance imaging)
Spinal stenosis
Postsurgical status, 1 4 months
after intervention
Postsurgical status, 2 6 months
after intervention (symptomatic
or asymptomatic)
Other diagnoses
accepted classification scheme for
activity-related low back pain would
allow for a better method of communicating between physical therapists
regarding the appropriateness and
efficacy of a treatment intervention
and would permit scientific investigation of treatment methods. Multicenter analyses of therapeutic interventions are impossible with the
current anatomically oriented diagnoses. This lack of a physical therapy
classification scheme does not preclude therapists from continuing to
search for ways of identifying the tissues from which pain arises, but the
focus of its importance becomes
shifted for the physical therapist. We
believe that the therapist must accept
the fact that, in most instances, it is
not possible to identify the tissues that
are causing pain.
"Based on Quebec Task Force on Spinal Disorders classification system.
Information Gained from
the Assessment
An appreciation of this trend in diag-
nosis raises the question: If the anatomical structure cannot be isolated,
what information is to be gained from
the physical testing used during the
low back assessment? As there is no
evidence that any specific test can
identify the tissues that are giving rise
to pain, what purpose can the examination fulfill?
One of the most important decisions
the physical therapist makes following
an examination of a patient with low
back pain is whether the history and
physical examination are consistent
with activity-related injuries to the
low back. This decision allows differentiation between activity-related mechanical disorders, which we believe
respond to physical therapy interventions, and nonrnechanical disorders,
which we believe require referral for
further medical evaluation.
As an expert in pathokine~iology,3~
the physical therapist diagnoses movement disorders associated with low
back pain via an analysis of posture,
adaptive changes resulting in altered
spinal mechanics, and patterns of
muscle weakness that lead to abnor-
Physical TherapyRolume 72, Number 4lApril 1992
i
ma1 loads being placed on the spine.
We believe that, when identified during the functional assessment, these
movement disorders provide excellent indications for physical therapy.
Table 3. Patient CImiJication of
Actiuip-Related Spinal Disorders
Category Deilnltlon
We propose that the proper intent of
the physical therapy low back evaluation should be to introduce various
stresses into the low back region in
both welight-bearing and non-weightbearing positions for the purpose of
reproducing symptoms. When the
various stresses provoke symptoms in
the standing position, they can then
be substantiated o r compared with
findings elicited with the patient in
the supine, prone, and side-lying positions. Th~eanalysis of the applied
stresses that lead to pain forms the
second component of the physical
therapy diagnosis. Because most patients with activity-related spinal disorders report that the upright posture is
more painful than lying down, we
believe that the "nociceptive biomechanics" (ie, those body positions and
forces of gravity and movement generated into and through the system
that provoke pain) are best analyzed
during weight bearing. McCombe et
al35 argue that determining movements that reproduce symptoms has
good reliability and should be considered in the assessment process.
Because physical therapists have extensive knowledge of spinal mechanics and use various active and passive
examination techniques to introduce
stresses into the musculoskeletal system, we believe their expertise
should be in analyzing and formulating a physical therapy diagnosis based
on the reproduction of pain through
the application of stresses. Documenting the stresses that stimulate a nociceptive response, including the presence or absence of pain and pain
location, helps standardize communication regarding diagnosis between
physical therapists, regardless of the
examining technique.
Classlflcatlon of Patients
C1assific:ation of a patient's symptoms
and history into meaningful, easily
understood groups helps provide di-
1
Acute injuty
2
Reinjulyiexacerbation of
previous injuty
3
rection for therapeutic intervention
and allows for rational application of
treatment. Many groupings are theoretically possible. For a grouping system
to be successful, however, an element
of simplicity is desirable; that is, it
must have nearly universal application
across a wide spectrum of clinicians.
We believe that the more complex a
classification system is, the less chance
that measurements obtained with the
system will be reliable.
We propose that most patients with
activity-related low back pain can be
placed into one of three categories
(Tab. 3). The first category is the patient with an acute injury. This category is depicted by a patient response
to the application of various stresses
proportional to both the time since
the injury and the physical trauma of
the injury. Because we have no reason to suspect otherwise, the healing
potential of tissues of the low back
should behave like any other connective tissue structures in the body 6 to
8 weeks postinjury. The response of
the injury of the low back should
therefore react accordingly to the
healing process. In the absence of
significant forces to cause reinjury
during the first 6 to 8 weeks postinjury, the intensity, frequency, and duration of the symptoms should be
expected to decrease as the healing
process progresses.
The intervertebral disk is distinct from
other connective tissues8~7~11-13~2~
in
that it does not have the same healing
potential as other connective tissues
in the spine. Mooney16 suggests that
acute injuries that never resolve o r
subside in intensity might be representative of pain of diskogenic origin.
The second category of patient is the
patient with reinjury (ie, the patient
who has exacerbations of a previous
injury). These patients describe low
back pain that is similar to the pain
they experienced previously. Their
descriptions of each episode of pain
and of the pattern of pain are relatively consistent. The symptoms often
diminish only to recur. These patients
may initially have injured their back
4 years previous, but the pain spontaneously disappeared. The following
year they may have reinjured the
same area, and the pain again spontaneously disappeared. Over the past
year and a half they may have reinjured their back four more times, but
they were unable to self-manage the
pain the last two times and are now
seeking medical help. These patients
are not experiencing new injuries,
rather they are continually applying
stress to previously injured tissues.
The phenomenon of recurrence of
low back pain is well substantiated.4136
The third category of patient is the
patient with chronic pain syndrome. In
order to properly understand this
group of patients, we must elm and
standardize the meaning of the "chronic pain" classification, particularly in
regard to the word "chronic." Many
patients with symptoms of many
months' o r even years' duration can
still have treatable low back pain.
These patients should not be thought
of as having chronic pain syndrome.
We argue that clinicians must recognize that the word "chronic" in the
description "chronic pain syndrome"
should not imply a time element. With
chronic pain, the primary observation
by the examining clinician is the patient's illness behavior and hopelessness.l7 In the patient with true chronic
pain syndrome, there is no longer a
direct relationship between application
of forces generated in the physical
examination and the pain response.
Instead, the patient's complaints are
compounded by anguish, disability,
illness behavior, emotional upheaval,
and discouragement.17
Table 4. Objectives of Treatment for
Activity-Related Spinal Disorders
A second objective is to introduce
Objective Definition
1
Pain modulation or promotion
of analgesia
2
Generate controlled forces to
promote nondestructive
movements
3
4
tion process. In our opinion, the treatment of pain as the primary focus is
indicated in only a specific group of
patients.
Enhance neuromuscular
performance
Biomechanical counseling
Therefore, following the patient's history and evaluation, and perhaps after
the initial trial course of treatment,
the clinician should attempt to place
the patient into one of these three
categories. The reason for this classification is to form a logical basis for
treatment. It is then critical to match
the objectives of treatment to the patient classification. To standardize
treatment of patients with low back
pain, specific objectives that encompass all treatment processes need to
be identified.
ObJecthresof Treatment
In some regards, there appears to be
more innovation, ingenuity, and, with
some interventions, mysticism, for
treatments of the low back than for
any other area of the body. How
might therapeutic intervention be
based on logic as well as science? We
propose that there are four independent objectives of treatment, within
which all therapeutic interventions
can be placed (Tab. 4).
The first objective is to modify pain
or promote analgesia. Numerous interventions are available to modulate
pain. Electromodalities, thermomodalities, or medications can be effective
means to minimize the patient's pain.
There is a major difference, however,
between relief of symptoms and spontaneous resolution of the problem. It
is appropriate to treat pain with the
purpose of moving into the subsequent phases of a planned rehabilita-
nondestructive forces into the injured
anatomical region of the body in order to promote movement or to increase the patient's physical activity.
The physical therapist has many techniques for placing controlled, nondestructive stresses into the low back
region to facilitate and encourage active movement by the patient in order
to expedite the patient's return to
physical activity. We feel that an early
return to activity has the most significant impact in the long-term management of the patient with low back
pain.19.s7 This objective is designed to
direct forces into and through the
injured region at an intensity, frequency, and duration that does not
cause further injury.
-
Table 5. Approaches Used to
Generate Controlled Forces
Type of
Approach
Approach
Manual
Categories of massage
Joint mobilization
Manipulation
Sofl tissue mobilization
Myofascial techniques
Traction
Stretching
Cross-friction
Rolfing
Acupressure/acupuncture
Mechanical
Mobilization tables
Treatment wedges/rolls
Heel-lifts
External supports
Active
The "passive extension press-up" is an
example of exercises that are suitable
for accomplishing this objective. Although often called an "exercise," we
feel that the press-up is an active mobilization tool designed to help alter a
patient's pain pattern. We believe that
it is not an exercise designed to
strengthen tissues and improve musculoskeletal and neuromuscular performance. For too long therapists
have become engrossed in arguments
over whether the effect of treatment is
focused on the disk, nerve roots,
joints, o r soft tissue. These academic
concerns have confused the real issue
for the patient: the analysis and subsequent effect of this mechanical stress
on the pain pattern.
Over the past several years, we have
witnessed a proliferation of techniques that have a variety of different
labels. Table 5 lists some of the mechanical, manual, and active approaches typically used to promote
improved function.
We believe that the reason there is
debate over the different techniques,
and the reason some clinicians become "disciples" of one particular
school of thought, is that each tech-
Traction
Muscle energy
Strain/counter-strain
Extension/flexion protocols
Contract/relax
nique has a unique explanation and
justification of the result. When challenged, clinicians often seek to justify
their rationale based on the uniqueness o r dissimilarity of the technique
instead of its similarities with other
techniques. Instead of pursuing the
commonalities, we have become accustomed to protecting the "turf."
For example, we believe a lumbar
joint mobilization maneuver cannot
only stress the joint. Soft tissue concurrently receives controlled stresses,
and afferent input is generated to the
central nervous system (CNS). The
same can be said for any technique.
We suggest that all of these manual
and mechanical techniques result in
one o r more of the following three
physiological responses:
1 . InJuence o n theJuid dynamics of
the injured area. It is well recog-
nized that fluid stasis, and an altered chemical environment of the
Physical TherapyRolume 72, Number $/April 1992
L
tissues, stimulates the nociceptive
system and impedes the healing
process. It is very difficult to find
any manual, mechanical, o r active
technique that does not influence
tissue fluid dynamics.
2. Generation of afferent input into
the CNS. Every technique results in
an increase in afferent input into
the C:NS. Although the patterns of
afferent input that occur at the CNS
level for various treatments are not
precisely known, two common results of enhanced afferent input are
mod~~lation
of pain and alterations
in the state of muscle c0ntraction.3~
A change may occur in a patient's
movement pattern or in the lumbar
or pelvic posture immediately following any of the lumbar techniques. We
believe, however, that it is obvious
that no chemical bonds have been
broken in the connective tissue and
that no bones have been "put back in
place." What has occurred, in our
view, is that a new and different resting tension (set) has been afforded
the muscle, which in turn results in a
change in the passive o r active movement patterns that alters the forces
directed into and absorbed by the
injured tissues.
3. Mod(fication of connective tissue.
We argue that, owing to the inherent strength of connective tissue,
this is the most difficult response
to achieve using typical physical
therapy techniques. Tissue can only
be altered if the force applied is
continuous and for a prolonged
period (ie, sufficient to alter the
cheniical bonding of the tissue).
We believe that any other force
that results in motion changes
must be a result of influences on
the neuromuscular system and its
attachments to the connective tissue, rather than on the connective
tissue structure itself.
In our view, any of the manual and
mechanical lumbar techniques used
skill full!^ and appropriately can be an
integral part of physical therapy practice. Clinicians must reconsider previous explanations of the effects of
these techniques and begin to base
such explanations on advances made
in the natural and behavioral sciences.
Which technique is used is most likely
of secondary importance. What appears most important is whether a particular technique carries a likelihood
of enhancing a quicker return to active
movement and function by the patient.
For too long therapists have viewed
such techniques as the end product.
The criticism regarding a passive approach toward treatment is justified
when such techniques are considered
the primary focus of rehabilitation.
The third objective of treatment is to
enhance neuromuscular performance
(ie, enhancing the muscle's potential
to resist deformation, o r stiffness,38 o r
to react with the desired force in
rapid manner to carry out the desired
movement or weight-bearing pattern).
Progressive resistance exercise programs, stabilization exercises, the Feldenkrais technique, tai chi, workhardening exercises, and functional
restoration o r physical reconditioning
programs are only some of the means
currently used to train or retrain the
neuromuscular system. Training not
only alters the muscle tissue and the
connective tissue matrix, but it affects
the nervous system as well.39-41
We believe neuromuscular retraining
is important because it achieves the
following:
1. Consistent forces placed on muscu-
loskeletal tissues can thicken the
enconnective tissue matrix,39~4~
hance neuromuscular conduction,40>41and improve the entire
neuromuscular mechanism.43
2. Muscles often act as shock absorb-
ers in the musculoskeletal system.
Neuromuscular training can result
in an increased "stiffness" of the
m ~ s c l e , 3which
~
perhaps optimizes
the patient's ability to attenuate
forces converging into the low
back region.
3. If clinicians use the results of the
evaluation to teach the patient
patterns of movement that minimize stress, then they must de-
velop the neuromuscular system's ability to carry out such
nondestructive movements. We
contend that training and exercise programs better prepare the
individual to self-manage his o r
her low back problem.
4 . Controlled exercise can reduce
emotional distress and illness behavior and expedite a return to
function. The sooner the patient
takes this active approach, the better the chance of self-management,
successfully returning to activity,
and long-term results. Active exercise programs have been consistently shown to be the most effective means of dealing with the low
back pr0blem.37~4-7
The last objective of treatment is to
biomechanically counsel the patient.48
If the patient is actively involved in a
physical therapy program 3 days per
week for 45 minutes per visit, this
involvement represents approximately
5% of the time that the patient is active. Realistically, if the patient's
activity-related low back disorder is
going to be changed, clinicians need
to educate the patient to self-manage
his or her low back pain during the
remaining 95% of his or her daily
activities.
The need for patient education is the
fundamental reason for focusing the
intent of the low back evaluation on
the forces or combination of forces
that reproduce the patient's symptoms. Patient education, based on an
understanding of biomechanics that
reproduce pain, is a critical component of any treatment program. The
patient and the clinician need to recognize that musculoskeletal injury
results in adaptive changes that alter
the force-attenuation capabilities of
the system. For example, if one were
to sustain an injury to the lumbar
apophyseal joint, creating articular
cartilage damage, then the shockabsorbing and weight-bearing capability of the joint, like any other synovial
joint, would be decreased. The
prompt return to activity and the setting of realistic goals are essential
components of a management strat-
Physical. TherapyNolume 72, Number 4/April 1992
-
Table 6. Treatment Plan for Activity-Related Spinal Disorders
Patlent Classlflcatlon
Objective
Acute
Reinjury
Pain modulation, analgesia
*ra
+
Application of controlled forces to
enhance movement
+*
*
Enhance neuromuscular performance
-
+*
Biomechanical counseling
*
**
Chronlc
a**=Strongly indicated and serves as a treatment goal.
b*=~ccasionallyindicated but is not a treatment goal.
'-=Not
back to the patient. These changes are
not only effective in helping to modlfy
the attention to pain, but also promote well being and a feeling of selfworth in the patient. In our view, the
treatment program should address the
changes that logically occur in any
deconditioning syndrome: mobility,
endurance, strength, and cardiovascular changes. This is why enhancing
neuromuscular performance is so
strongly indicated in this patient population, whereas the other three objectives have little o r no indication
and have a propensity to perpetuate
the syndrome.
typically indicated or a treatment goal.
egy. This is often difficult for the patient to accept, because the patient
typically expects a permanent "cure."
In most situations, self-management is
a more realistic goal.
that the natural course of the low
back condition will probably not be
altered. Instead, these methods
should be used with the sole intent of
facilitating an early return to activity.
Matchlng the ObJecthresof
Treatment to Patlent
Classification
The patient with reinjury must develop the neuromuscular capabilities
to assist with self-management of his
o r her musculoskeletal injury, because there is a high probability of
continued recurrence. Enhancing neuromuscular performance is strongly
indicated and serves as a treatment
goal with this patient population, because the state of their musculoskeletal health is critical if they are to avoid
reinjury and maintain function. We
contend that biomechanical counseling is also an extremely important
objective with these patients, because
the limits of the physiological capacity
of injured tissue must be recognized
and respected. Use of pain modulation techniques o r generation of controlled forces in the injured region
has very limited indications and is
appropriate only if the guidelines for
acute injury of musculoskeletal tissues
are followed.
The final management consideration
is decidlng which category of patients,
from the classification scheme presented in Table 3, are indicated for a
particular treatment objective (Tab. 6).
Clinical experience suggests that
some therapeutic interventions are
appropriate for patients in one category, but are not indicated for patients in another category, because
the natural course of the problem is
unlikely to change. The following is a
brief explanation of Table 6.
The acutely injured patient, whose
history and physical examination suggest injury commensurate with the
known response and time periods for
the healing of musculoskeletal tissue,
should initially be treated for relief of
pain and then with therapeutic techniques designed to facilitate an early
return to activity. The intent of treatment is to maximize the patient's
healing potential and to restore movement as soon as possible without
exacerbation of injury. Many manual
and mechanical techniques may be
effective as adjuncts to modalities that
promote analgesia, but we believe
28 / 268
In our view, the patient with true
chronic pain syndrome can no longer
be treated with the emphasis on pain
modulation. Instead, the focus should
be on augmenting function and on
increasing physical activity, especially
if changes in functional range of motion and physical work capacity can
be measured and provided as feed-
The fact that low back pain is an epidemic is well recognized. No one can
argue that more research is needed. It
is also apparent, however, that evaluation and treatment biases must change
and that clinicians must develop a
more logical rationale for treatment.
Only then can our efforts assist in curtailing the low back problem.
We fully recognize that socioeconomic,
medicolegal, and symptom-magnification factors must be considered.
Changes must occur at these levels
and in all aspects of the treatment p r o
cess if success is to occur. That is why
we believe this model is a more appropriate vehicle for facilitating change
in the approaches used in the physical
therapy management of patients who
have low back pain. This model provides a strategy that recognizes the
present understanding of the disorder,
rather than a reactionary response influenced by reimbursement trends and
changing treatment biases. The model
also places treatment approaches, both
current approaches and perhaps those
to be developed in the future, into the
context of a physical therapy diagnosis
and patient classification.
We are hopeful that this model will
be carefully examined, debated, and
subjected to tests of reliability by the
profession. We suggest change not
because of evidence of failure in curtailing the low back problem, but
more importantly because such a
model acknowledges advances made
Physical Therapyllrolume 72, Number 4/April 1 9 2
'i
\
in assessment and treatment options
and recognizes the potential for the
development of other advances in the
future. In this regard, we believe that
the basic framework of the model will
endure.
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Physical TherapyNolume 72, Number 41April 1992
Back Pain
Carl P DeRosa and James A Porterfield
PHYS THER. 1992; 72:261-269.
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