Low Back Pain With Mobility Deficit

Original Editor -Lieveld Jean Yves, Mostafa Mataichi, Ismael El Habouchi and David Herteleer

Top Contributors - Kelan Krohe, Kim Jackson, Shannon Petersen, Oyemi Sillo and Evan Thomas  

Contents

Definition

A Classification Approach for patients with Low Back Pain has been used as a guide to sub-group patients based on their clinical signs and symptoms[1]. In 2012, Low Back Pain Clinical Practice Guidelines were published.[2] [30]
Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association

  • Describes evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessment of outcome, for musculoskeletal disorders[2]
  • Identifes interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions[2]
  • Identifies appropriate outcome measures
  • Overall, the purpose of these Low back Pain Guidelines is to describe literature and make recommendations for:
    • Treatment for associated subgroups of low back pain
    • Treatments that have supported evidence
  • Classifies patients into groups based on clinical characteristics and matching these patient subgroups to management strategies likely to benefit them will improve the outcome of physical therapy interventions[2]
    • Evolution of Treatment Based Classification: Fritz, Cleland, Childs[1]
    • 3 distinct differences from the Treatment Based Classification Approach to Low Back Pain
    • Categories incorporate International Classification of Functioning, Disability, and Health (IFC) impairments of body functions terminology
    • Addition of the low back pain with “related cognitive or affective tendencies” and “generalized pain”
    • Addition of the patients acuity level
  • Low Back Pain Clinical Practice Guidelines is divided into 6 categories, upon which this page will focus on Low back pain with mobility deficits

Clinically Relevant Anatomy

The lumbar spine has several distinguishing characteristics[3]:

  • The lower the vertebra is in the spinal column, the more weight it must bear. The five vertebrae of the lumbar spine (L1-L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso.
  • The lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury.
  • The lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when walking and running.


The sacroiliac joint (SI-joint) connects the sacrum (triangular bone at the bottom of the spine) with the pelvis (iliac bone that is part of the hip joint) on each side of the lower spine. It transmits all the forces of the upper body to the pelvis and legs. There is not a lot of motion in the joint and it is very strong and stable.[3]

Epidemiology-Etiology

Low back pain (LBP) has a major medical and economic impact in the world.[4] The impact of severe LBP increases with advancing age and is a strong contributor to mobility disability.[5]  Obese persons with LBP have increased disability, higher pain severity and worse functional capacity than non-obese counterparts.[6] The causes of LBP appear to be complex and multifactorial, with both biological and psychosocial components associated with chronicity.[7] There is a significant relationship between reduced hip mobility and low back pain as the reduction in of both passive and active movement (ROM) has been demonstrated in general[8] . Several researchers (Keatan et al.; 2005) described low back pain as the leading cause of activity, limitation and work absence throughout much of the world and is associated with an enormous economic burden.[9] In spite of the large number of potentially pain generating structures and pathological conditions that can give rise to LBP in most cases approximately eighty-five to ninety percent have no identifiable cause which are defined as non-specific low back pain (NSLBP) (Lethola, 2016). The loss of mobility and functional capacity resulting from back pain are serious threats to public health as they are predictive of chronic disability.[10]

Characteristics-Clinical Presentation

For acute low back pain with mobility deficits, the distinguishing movement/pain characteristic is that the patient demonstrates restricted spinal range of motion and segmental mobility, and that the patient’s low back and low back–related lower extremity symptoms are reproduced with provocation of the involved segments, with intervention strategies focused on reducing pain and improving mobility of the involved spinal segments.[11]


For subacute low back pain with mobility deficits the distinguishing movement/pain characteristic is pain that occurs with mid- to end-ranges of active or passive motions, with intervention strategies focused on movements that in¬crease movement tolerances in the mid- to end-ranges of motions.[11]

According to the ICF (International Classification of Functioning, Disability and Health), codes of low back pain with (sub)acute low back pain with mobility deficits leads to the following problems on body functions, body structure, and activities and participation

Acute Low Back Pain with Mobility Deficits

The ICD diagnosis of acute low back pain with mobility deficits are made with a reasonable level of certainty when the patient presents with the following clinical findings.[11]

  • Acute low back, buttock, or thigh pain (duration of 1 month or less)
  • Restricted lumbar range of motion and segmental mobility
  • Low back and low back–related lower extremity symptoms reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments.[2]

Body Functions:

  • Pain in back
  • Pain in body part, specified as pain in buttock, groin, and thigh
  • Mobility of several joints
  • Mobility of joint functions, specified as mobility in a vertebral segment

Body Structure:

  • Thoracic vertebral column
  • Lumbar vertebral column
  • Joints of pelvic region

Activities and participation:

  • Bending

Sub-acute Low Back Pain with Mobility Deficits

The ICD diagnosis of sub-acute low back pain with mobility deficits are made with a reasonable level of certainty when the patient presents with the following clinical findings.[11]

  • Sub-acute, unilateral, low back, buttock, or thigh pain
  • Symptoms reproduced with end-range spinal motions and provocation of the involved lower thoracic, lumbar, or sacroiliac segments
  • Presence of thoracic, lumbar, pelvic girdle, or hip active, segmental, or accessory mobility deficits.[2]

' 'Body Functions:

  • Pain in back
  • Pain in body part, specified as pain in buttock, groin, and thigh
  • Mobility of several joints
  • Mobility of joint functions, specified as mobility in a vertebral segment

Body Structure:

  • Thoracic vertebral column
  • Lumbar vertebral column
  • Joints of pelvic region
  • Muscles of pelvic region
  • Hip joint
  • Muscles of thigh
  • Ligaments and fascia of thigh

Activities and Participation:

  • Bending

Differential Diagnosis [2]

Acute Low Back Pain with Mobility Deficits:

Restricted spinal ROM, segmental mobility, and low back and low back-related lower extremity symptoms are reproduced with provocation of involved segments
Diagnosis:

  • Acute low back, buttock or thigh pain for less than 1 month
  • Restricted lumbar ROM and segmental mobility
  • Low back and related LE pain reproduced with provocation

Sub-acute Low Back Pain with Mobility Deficits:[2]

  • Subacute, unilateral, low back pain, or thigh pain
  • Symptoms reproduced with end-range spinal motions and provocation of involved lower thoracic, lumbar, or SI segments
  • Present with mobility deficits

Chronic Low Back Pain with Mobility Deficits[8]

  • The symptoms are more than half the time present during a period of 12 month, occurring in a single or in multiple episodes.

Recurrent Low Back Pain with Mobility Deficits[8]

  • The symptoms are less than half the time present during a period of 12 month, occurring in multiple episodes over the year.

Diagnostic Procedures

Objective assessments of lumbar motion can be achieved by a variety of methods:

  • Examination of regional motion using an inclinometer ROM,
  • Finger-to-floor distance
  • Schober Index
  • Visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans[12].


However, associations between these ROM measures and the patient rated measures are low[13]

Outcome Measures

ODIs may be more useful than VAS scores in the clinical setting when considering functional movement parameters[14].

Examination

There are three important examination-components to examine a patient with low back pain and lumbar mobility deficit. The first one is to visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans.


There is no imaging indicated if “reduced lumbar spinal movement with low back pain” is described as an acute symptom which lasts 1 month or less and with the absence of red flag signs[12].[ It’s important to know that these investigations do not identify the specific causes of pain (low sensitivity and specificity), but this research is mostly used with serious conditions. The second one is to take a detailed and specific history of the patient. Based on this history we get an overview of possible clues to find the cause of low back pain. And at least there is the last component, the physical examination. This consists of a series of tests which helps to find the causes of pain with which the patient struggles.[15]


Objective assesments of the lumbar motion can be achieved by a variety of methods

  • Examination of the regional motion using an inclinometer ROM
  • Finger-to-floor distance
  • Schober-index

However, associations between these ROM measures and the patient rated measures are low[13]

Low Back Pain - Red Flags


Patients with back pain for the first time (80%) usually have 1 or more red flags, but it is rarely that they have a serious condition. Overall it is important for a physician to be aware of certain severe signs such as:[16][15]

  • Cauda equina syndrome
  • Major intra-abdominal pathology
  • Infections
  • Malignancy
  • Fractures

Physical Impairment Measures Examination Test

For more information about Examination of the Lumbar Spine see here

I. Lumbar ROM - Quadrant

People with low back pain frequently show movement control impairments of the lumbar spine in the sagittal plane: flexion and extension. The research of C.M. Bauer et Al. noted also a linear effect of Low Back Pain intensity on variability of lumbar movement patterns. It’s therefore we recommend therapists to examine those specific movements in the sagittal plane.[17]

II. Lumbar Spine Segmental Mobility Assessment:

In an article of J.M. Fritz et Al. the mobility of each spinal segment of the lumbar spine was graded as normal, hypomobile, or hypermobile by using PA-techniques (posterior to anterior gentle pressure on the processus spinosus with the hypothenar eminence). Thereafter the patient was categorized in either the presence of hypomobility or the presence of hypermobility. If hypomobility was judged to be present at any level of a subject’s lumbar spine, the subject was categorized as having hypomobility. This examination technique should be interpreted with other information you have obtained.[18] [19]

III. Pain Provocation with Segmental Mobility Testing

IV. Judgments of Centralization during Movement Testing

  • Patient flex forward multiple times asking about any changes in pain.
  • Repeat this with extension and lateral flexion.
  • Look for a centralization of pain with repeated motion in a specific direction.

V. Prone Instability Test

VI. Judgments of the presence of aberrant movement

  • Measured by painful arc with flexion or return from flexion. If patient complains of pain when returning to standing from flexion or feels a catch, this is a positive test.

VII. Straight Leg Raise

VIII. Slump Test

IX. Trunk Muscle Power and Endurance

  • Check Trunk Flexors, Extensors, Lateral Abdominals, Transversus Abdominis, Hip Abductors, and Hip Extensors for strength looking for any muscle imbalances.

X. Passive Hip Internal Rotation, External Rotation, Flexion, and Extension

The article of T. Consmüller et Al. presents the Epionics SPINE, a measurement-instrument to evaluate the lumbar and thoraco-lumbar movement (up to 24h) and is also used for the assessment of the shape of the back. This may provide a clinical and reliable solution for the evaluation of the lower back pain.[20]

Mental Impairment Measures:

  1. Depression
  2. Yellow Flags
  3. Fear Avoidance Beliefs Questionnaire

Disability Questionnaire:

The RDQ (modified Roland Disability Questionnaire, range: 0-23) is a measuring instrument which is also used for detecting back pain related functional limitations.[21] [22]

Medical Management

  • The patients with low back pain need to be stimulated and motivated to remain active and keep doing ADL, instead of resting in bed which has many disadvantages: joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thrombo-embolism.
  • To develop coping-strategies through education
  • To avoid movements such as: twisting and bending

Another medical treatment is the prescription of certain drugs, such as:[16]

  • Analgesics, the research of JM. Williams et Al. shows us that reducing pain by analgesics does not alter the lumbar range of motion in chronic patients with low back pain.[4]Level of evidence 1B
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Muscle relaxants

These drugs can ensure that patients stay active without feeling pain, so that they can function in their daily live.[16] [15]

Physical Therapy Management

Acute Low Back Pain with Mobility Deficits[2]

1. Aim and strategy of therapy in this case:

1.1 Manual therapy procedure (thrust or non-thrust) to diminish pain and improve segmental spinal or lumbopelvic motion
1.2 Therapeutic exercise to improve or maintain spinal mobility
1.3 Patient education that encourages the patient to return to or pursue an active lifestyle


2. Example of full therapy:[18] [19] [2]

  • Joint mobilizations or manipulations on thoracic spine like the Supine Thoracic Thrust Manipulation. For more information on Manual Therapy see here


2.2 Therapeutic Exercises:

  • Core Stabilization including engaging the transverse abdominus and multifidus. Biofeedback may be useful.
  • Anterior and posterior pelvic tilts
  • Bridges
  • Quadruped for cat/camel stretching

2.3 Patient Education:

  • Posture
  • Home Exercise Program

Subacute Low Back Pain with Mobility Deficits[2]


1. Aim and strategy of therapy in this case:

1.1 Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility
1.2 Therapeutic exercise to improve or maintain spinal and hip mobility
1.3 Focus on preventing recurring low back pain episodes through use of:
• Therapeutic exercise that address coexisting coordination impairments, strength deficits, and endurance deficit.
• Education that encourages the patient to pursue or maintain an active lifestyle

2. Example of full therapy:

2.1 Manual Therapy:

  • Joint mobilizations or manipulations on lumbar spine at the hypomobile segment: See "Sidelying Lumbar Thrust Manipulation" above
  • Joint mobilizations or manipulations on thoracic spine: See "Supine Thoracic Thrust Manipulation" above
  • Joint mobilizations or manipulations on hip/pelvis:

2.2 Therapeutic Exercises:

  • Stretching into limited motion
  • Core Stabilization: bicycle kicks, planks
  • Wall slides and partial lunges keeping a neutral spine
  • Swiss Ball marching, abdominal crunches
  • Quadruped with opposite arm and leg reaches
  • Bridging on heels (not flat foot)
  • Scapular Strengthening in prone

2.3 Patient Education:

  • Posture in more functional activities
  • Home Exercise Program

Chronic and recurrent low back pain with mobility deficit. Effectiveness 


1. Aim and strategy of therapy in this case:[8]

1.1 To reduce pain and upgrade functions in individuals with non-specific chronic or recurrent LBP with concurrent through exercise therapy (Hip rotation stretching, multi-directional hip stretching and hip strengthening).

2. Example of full therapy:[8]

2.1 Therapeutic Exercises:

2.1.1 HIP Rotation stretching excercice
Frequency; 5 times a week
Duration; each stretch is to be held for 30 seconds
Repeat; 3 times
All stretches most be done on both sides


2.2.2 Multi-directional hip stretching home exercise program

Frequency; 5 times a week
Duration; each stretch is to be held for 30 seconds
Repeat; 3 times
All stretches most be done on both sides

  • Crook lying
  • Lunge
  • Sitting – Hip medial rotation, flexion and abduction stretch
  • Standing – Groin stretch
  • Sitting – Groin stretch
  • Prone hip medial rotation – Leg fall out stretch
  • Prone hip lateral rotation – Leg fall in stretch


2.2. 3 Strengthening home exercise programme

Frequency; 5 times a week
All stretches most be done on both sides

Weeks 1 & 2

  • Clams
  • Prone hip external rotation with theraband
  • Side-lying hip abduction
  • Quadruped hip extension
  • Single leg stand
  • Prone hip medial rotation – Leg fall out stretch
  • Prone hip lateral rotation – Leg fall in stretch

Weeks 3 & 4

  • Quadruped hip extension
  • Single leg bridge
  • Single leg squats
  • Lateral step exercise
  • Standing hip rotation exercise
  • Prone hip medial rotation – Leg fall out stretch
  • Prone hip lateral rotation – Leg fall in stretch

Weeks 5 & 6

  • Single leg squats
  • Single leg bridge
  • Lateral step exercise
  • Standing hip rotation exercise with theraband
  • Prone hip medial rotation – Leg fall out stretch
  • Prone hip lateral rotation – Leg fall in stretch


Stretching program using the Global Postural Reeductaion method showed effective at improving pain, function, some quality of life aspects (emotional, limitations in physical functioning, vitality and mental health) and had no effect on depressive symptoms in patients with chronic low back pain[23]


The GPR is a therapy which is based on the muscle chains of the muscular system wherein a shortening can occur. Reasons:

  • constitutional factors
  • Behavioral factors
  • Psychological factors

The main goal of this therapy is to stretch the shortened muscles using the creep of viscoelastic tissue and to improve contraction of the antagonist muscles, which leads thus to avoiding postural asymmetry.[24]

Method: 

A. Lying on back with the legs extended.
B. Lying on back with the legs flexed.
C. Standing with the body leaning forward’.
D. Sitting with legs extended.
E. Standing in the center

Key Research

  • Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52.[18]
  • Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, Butts K. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self-imposed motion using dynamic MRI. BMC Musculoskelet Disord. 2007 Jan 29;8:8. [19]
  • Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.[21]

Resources

• Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.[21]

Clinical Bottom Line

Clinical Practice Guidelines can be used by clinicians in examination, differential diagnosis, and intervention planning for patients with low back pain. These evidence-based guidelines can be applied to patients with acute and sub-acute low back pain. This page has summarized the guidelines for patients in the categories of Acute and Sub-acute Low Back Pain with Mobility Deficits.

References

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  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Delitto A, George S.Z. et al, Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orhtop Sports Phys Ther. 2012;42(4):A1-A57
  3. 3.0 3.1 Spinal anatomy and backpain. P.F. Ullrich. Spine-health, trusted information for backpain
  4. Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt MJ, Lee MJ. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S54-68
  5. Macfarlane GJ, Beasley M, Jones EA, Prescott GJ, Docking R, Keeley P, McBeth J, Jones GT; MUSICIAN Study Team. The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study. Pain. 2012 Jan;153(1):27-32
  6. Fanuele JC, Abdu WA, Hanscom B, Weinstein JN. Association between obesity and functional status in patients with spine disease. Spine (Phila Pa 1976). 2002 Feb 1; 27(3):306-12.
  7. Laird RA, Kent P, Keating JL. Modifying patterns of movement in people with low back pain -does it help? A systematic review. 2012 Sep 7;13:169. doi: 10.1186/1471-2474-13-169.
  8. 8.0 8.1 8.2 8.3 8.4 Sarah Winter et al. Effectiveness of targeted home-based hip exercises in individuals with non-specific chronic or recurrent low back pain with reduced hip mobility. Journal of back and musculoskeletal rehabilitation, 2015
  9. Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005 Jul 26;13:13
  10. Nocera J, Buford TW, Manini TM, Naugle K, Leeuwenburgh C, Pahor M, Perri MG, Anton SD. The impact of behavioral intervention on obesity mediated declines in mobility function: implications for longevity. Journal of aging research. 2011;2011.
  11. 11.0 11.1 11.2 11.3 Kenneth A. Olson. Manual Physical Therapy of the Spine. 2008. P. 118
  12. 12.0 12.1 Anthony D., Steven G., Linda V.D. et al. Low Back Pain clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical therapy association. Journal of Orthopaedics & Sports Physical Therapy. 2012;42 (4)
  13. 13.0 13.1 Mieritz PM. Bronfort G. Hartvigsen J. Regional Lumbar Motion and Patient REGIONAL LUMBAR MOTION AND PATIENT-RATED OUTCOMES: A SECONDARY ANALYSIS OF DATA FROM A RANDOMIZED CLINICAL TRIAL. Journal of Manipulative and Physiological Therapeutics (2014) Volume 37, Number 9
  14. Ruiz FK. Bohl DD. Webb ML. Russo GS. MD. Grauer JN. Oswestry Disability Index is a better indicator of lumbar motion than the Visual Analogue Scale. The Spine Journal 14 (2014) 1860–1865
  15. 15.0 15.1 15.2 David G.B., Andrei C. Diagnosis and Treatment of acute low back pain. Fast Facts: Low Back Pain. Health Press. 2012
  16. 16.0 16.1 16.2 Casazza B.A. Diagnosis and Treatment of Acute Low Back Pain. American Family Physician.2012;85(4):343-50
  17. Bauer CM, Rast FM, Ernst MJ. et al. Pain intensity attenuates movement control of the lumbar spine in low back pain, M.J Electromyogr Kinesiol. 2015 Dec;25(6):919-27.[7]
  18. 18.0 18.1 18.2 Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52
  19. 19.0 19.1 19.2 Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, Butts K. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self-imposed motion using dynamic MRI. BMC Musculoskelet Disord. 2007 Jan 29;8:8.
  20. Consmüller T, Rohlmann A, Weinland D, Druschel C, Duda GN, Taylor WR. Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion. Eur Spine J. 2012 Nov;21(11):2170-80
  21. 21.0 21.1 21.2 Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.
  22. Caporaso F, Pulkovski N, Sprott H, Mannion AF. How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non)specific low back pain undergoing physiotherapy?. Eur Spine J. 2012 May;21 Suppl 2:S187-95
  23. Lawand P. Lombardi IJ. Jones A. Sardim C. Ribeiro LH. Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: A randomized controlled trial. Joint Bone Spine 82 (2015) 272–277
  24. Bonetti F, Curti S, Mattioli S et Al. Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010 Dec 16;11:285.