Low Back Pain With Mobility Deficit

Original Editor - Kelan Krohe, Deidra Blin, Kate Fielitz, and Adam Van Der Molen as part of the Des Moines University Student Project

Top Contributors - Kelan Krohe, Kim Jackson, Admin, Shannon Petersen, Oyemi Sillo, Evan Thomas, David Herteleer, Rucha Gadgil and Lauren Lopez  

Introduction [edit | edit source]

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].

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          

 

Impairment/Function-Based Diagnosis[edit | edit source]

For information regarding low back pain, see the following:

Low Back Pain

Low Back Pain Guidelines

Outcome Measures[edit | edit source]

Oswestry Disability Index

Roland‐Morris Disability Questionnaire

Medical Outcomes Survey Short Form-36

Examination[edit | edit source]

  • Low Back Pain RED FLAGS[2]
  • Physical Impairment Measures[2]
  1. Lumbar ROM - Quadrant
  2. Segmental Mobility
  3. Pain Provocation with Segmental Mobility Testing
  4. 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.
  5. Prone Instability Test
  6. 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.
  7. Straight Leg Raise
  8. Slump Test
  9. 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.
  10. Passive Hip Internal Rotation, External Rotation, Flexion, and Extension     
  • Mental Impairment Measures
  1. Depression
  2. Yellow Flags
  3. Fear Avoidance Beliefs Questionnaire

Differential Diagnosis[edit | edit source]

 Acute Low back pain with mobility deficits:[2]

  • 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


Subacute 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

Intervention Techniques[2][3][4][5][edit | edit source]

- Thrust and non-thrust manipulation to reduce pain, improve mobility

          - Spinal Manipulation
- Trunk coordination, strengthening, and endurance exercises 

Acute Low Back Pain with Mobility Deficits
[edit | edit source]

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


Examples:

Manual Therapy:

  • Joint mobilizations or manipulations on lumbar spine at the hypomobile segment using either supine or sidelying techniques

          - Sidelying Lumbar Thrust Manipulation:

  

       

  • Joint mobilizations or manipulations on thoracic spine:

          - Supine Thoracic Thrust Manipulation:

   


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

Patient Education:

  • Posture
  • Home Exercise Program

Subacute Low Back Pain with Mobility Deficits[edit | edit source]

  • Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility
  • Therapeutic exercise to improve or maintain spinal and hip mobility
  • Focus on preventing recurring low back pain episodes through use of:

          - Therapeutic exercise that address coexisting coordination impairments, strength deficits, and endurance deficits
          - Education that encourages the patient to pursue or maintain an active lifestyle

Examples:

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:

  



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

Patient Education:

  • Posture in more functional activities
  • Home Exercise Program

Classification Criteria[2][edit | edit source]


 Symptoms
 		Impairments
 		Interventions
Acute Low Back Pain with Mobility Deficits
 • Acute low back, buttock, or thigh pain
• Unilateral pain
• Onset of symptoms often linked to a recent unguarded/awkward movement or position
 • Lumbar range of motion limitations
• Restricted lower thoracic and lumbar segmental mobility
• Low back and low back related lower extremity symptoms are reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments
 • Manual therapy procedure (thrust or non-thrust) to diminish pain and improve segmental spinal or lumbopelvic motion
• Therapeutic exercise to improve or maintain spinal mobility
• Patient education that encourages the patient to return to or pursue an active lifestyle
Subacute Low Back Pain with Mobility Deficits
 • Subacute, unilateral, low back, buttock, or thigh pain
• May report sensation of back stiffness
 • Symptoms reproduced with end-range spinal motions
• Symptoms reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments
• Presence of 1 or more of the following:
  1. Restricted thoracic ROM and associated segmental mobility
  2. Restricted lumbar ROM and associated segmental mobility
  3. Restricted lumbopelvic or hip range of motion and associated accessory mobility

• Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility
• Therapeutic exercise to improve or maintain spinal and hip mobility
• Focus on preventing recurring low back pain episodes through use of:

     - Therapeutic exercise that address coexisting coordination impairments, strength deficits, and endurance deficits

      - Education that encourages the patient to pursue or maintain an active lifestyle


 

 Summary  [edit | edit source]

  • 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 subacute low back pain. This page has summarized the guidelines for patients in the categories of Acute and Subacute Low Back Pain with Mobility Deficits.

Presentations[edit | edit source]

Treatment Based Classification Approach to Low Back Pain


Recent Related Research (from Pubmed)[edit | edit source]

Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1fC8RWxzfM4ExlHi6zqMBFUhSIshGUxz_9ihX5q2CBADhB6sGT|charset=UTF-8|short|max=10: Error parsing XML for RSS


References[edit | edit source]

  1. ↑ 1.0 1.1 Fritz JM, Cleland JA et al. Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopadic Sports Physical Therapy. 2007;37(6):290-302.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 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. ↑ Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifiying Patients with Low Back Pain who Demonstrate Short-Term Improvement with Spinal Manipulation. SPINE. 2002;27:2835-2843
  4. ↑ Childs JD, Fritz JM, Flynn TW et al. A Clinical Prediction Rule to Identify Patients with Low Back Pain most likely to benefit from Spinal Manipulation: a validation study. Ann Intern Med . 2004;141:920-928.
  5. ↑ Cleland JA, Fritz JM et al. Comparison of the Effectiveness of Three Manual Physical Therapy Techniques in a Subgroup of Patients with Low Back Pain who Satisfy a Clinical Prediction Rule. SPINE. 2009;34(25):2720-2729.


  • Fritz JM, Delitto AD, Erhard RE. Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. SPINE. 2003;28(13):1363-1372.
  • "Medical Outcomes Study Short Form-36." 36-Item Short Form Survey Instrument. RAND Corporation, 1 Mar. 2010. Web. 23 Oct. 2012. http://www.rand.org/health/surveys_tools/mos/mos_core_36item_survey.html


Retrieved from "https://www.physio-pedia.com/index.php?title=Low_Back_Pain_With_Mobility_Deficit&oldid=122606"