Regional Interdependence in Low Back Pain: Interventions

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 REGIONAL INTERDEPENDENCE

  • Regional interdependence is the concept that a musculoskeletal treatment targeting a specific area of the body could have effects in another, seemingly unrelated, part of the body[1].
  • There is a growing body of evidence to support the treatment of Low Back Pain through interventions aimed at the thoracic spine and the hip joints. 

EXAMINATION 

INTERVENTIONS


Thoracic Spine[2] 

Thoracic Manipulation

  • One case study reported improved outcomes in patients with chronic low back pain after utilizing the following intervention aimed at the thoracic spine. 
  • Supine Thoracic Posterior to Anterior Thrust Manipulation[2]
   

Hip[3][4][5][6][7]

Hip Manipulation

  • One case series found that the use of hip manipulaiton was beneficial for their patients with low back pain. [7]
  • Supine Long Axis Distraction Thrust Manipulation
  

Hip Mobilization

  • Multiple studies, including randomized controlled trials and case studies, found that mobilization to the hip joints resulted in improved outcomes in their patients with low back pain. [3][4][6][7]
  • Supine Hip Caudal Glide Mobilization

   Supine Hip Caudal Glide.JPG


  • Prone Hip Posterior to Anterior Mobilization

   Prone Hip Posterior to Anterior Glide.JPG


  • Hip Posterior to Anterior Mobilization with Flexion, Abduction, and External Rotation

Hip PA with flex, abd, ER.JPG

  • Hip Anterior to Posterior Mobilization with Flexion, Adduction, and Internal Rotation      

Hip AP with flex add IR.JPG

  

HIp Therapeutic Exercise

  •  Strengthening

          + One case study found that the following strengthening exercise helped to decrease low back pain. [5]

          - Hip Abduction with slight extension and internal rotation

   Hip Abduction with IR.JPG

  •  Flexibility

          + Two studies found the following stretches to be useful in the treatment of low back pain.[4][3]

          - Supine Iliopsoas Stretch

   Supine Iliopsoas Stretch.JPG

          - Prone Rectus Femoris Stretch

   Prone Rectus Femoris Stretch.JPG

          

Outcomes



Articles Body Region Treated Level of Evidence Improved Oswestry Disability Index Score Improved Fear Avoidance Behavioral Questionairre Score Improved Global Rating of Change Score Improved Modified Spinal Stenosis Scale Score Improved Pain Pressure Threshold Decreased Pain Improved Function
Burns et al. Hip 4 X X X X
Cibulka Hip 4 X X X
Oliviera et al. Thoracic Spine 2 X X
Whitman et al. 2003 Hip 4 X X X
X
Whitman et al. 2006 Hip 2 X X X X X
Lejkowski & Poulsen Hip 4 X X
          - An "X" denotes improvement in each specific category regardless of statistical significance. 


Clinical Implications

  • Utilizing manual therapy interventions targeted at the hip and thoracic spine along with therapeutic exercise has been shown to provide improved outcomes for patients with low back pain. Clinicians should consider these interventions along with treatments focused on the low back to treat the entire patient and achieve improved results. Additional information can be found in the references listed below.

References

  1. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/18057674 (accessed 26 Oct 2013).
  2. 2.0 2.1 Oliveira RF, Liebano RE, Costa LCM, Rissato LL, Costa LOP. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther 2013;93(6):748-756. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/23431209 (accessed 28 Oct 2013).
  3. 3.0 3.1 3.2 Whitman JM, Flynn TW, Fritz, JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am 2003;14:77-101. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/12622484 (accessed 29 Oct 2013).
  4. 4.0 4.1 4.2 Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31(22):2541-2549. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/17047542 (accessed 29 Oct 2013).
  5. 5.0 5.1 Cibulka MT. Low Back Pain and its Relation to the Hip and Foot. J Orthop Sports Phys Ther 1999;29(10):595-601. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/10560068 (accessed 26 Oct 2013)
  6. 6.0 6.1 Lejkowski PM, Poulsen E. Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments. Journal of Bodywork & Movement Therapies 2013;17:448-452. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/24139002 (accessed 29 Oct 2013).
  7. 7.0 7.1 7.2 Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. Journal of Manual and Manipulative Therapy 2011;19(2):100-107. Pub Med Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172945/ (accessed 29 Oct 2013).