Physiotherapy Management of Low Back Pain

1. Exercise Therapy in the
Management of Low Back
Pain
JOHNSON OLUBUSOLA

2. Preamble
 There is very little relationship between physical pathology and
associated pain and disability
 We regard low back pain (LBP) as an injury, but most episodes occur
spontaneously with normal everyday activities
 High-tech imaging tells us very little about simple backache
 It is essential to improve the efficiency of treatment of chronic/recurrent
LBP
8/25/2015
2

3. Low Back Pain
 LBP is a very common disorder (Woolf and Pfleger, 2003)
 LBP, identified as the leading disability contributor (Goubert et al, 2004)
 LBP reduces level of physical capacity (Hodges et al, 2009; Wang et al,
2014)
 Psychological effects (Gatchel et al, 2007; Nicholas et al, 2011) and
reduction in the quality of life
 Patients ought to undergo health care (Deyo et al, 2006, Haldeman and
Dragenais, 2008)
8/25/2015
3

4. Why LBP
Percentage Restriction of Activity by Locations of pain
 Head 6 %
 Neck / Shoulder 7 %
 Low back 11 %
 Knees 8%
 Ankle/Foot 5 %
8/25/2015
4

5. Epidemiology
 84% of adults will experience an episode of LBP at
some point during their lifetimes
 80-90% recover within 6 weeks with or without
treatment
 80% become recurrent (Goubert et al, 2004;Weiner
and Nordin, 2011)
8/25/2015
5

6. Classification by A etiology
 Non- Specific: 90% of LBP cases is non-specific
 Specific: Specific low back pain is related to specific pathologies and can
be diagnosed early through warning signs including Neoplasm, Infectious,
vascular, metabolic, or endocrine related (Wipf & Deyo RA, 1995). E.gs
symptomatic herniated disk 3-4%, ankylosis 0.3 - 5%, compression fractures
4%, and spinal malignancy 0.7% (Van Tulder, 2004)
8/25/2015
6

7. 8/25/2015
7
Classification by duration
 Acute: 6weeks or less
 Intermediate: > 6 weeks< 12weeks
 Long term: > 12 weeks
 Acute and long term LBP warrant separate considerations as
they may respond differently to the same interventions
(Sierpina 2002; van Tulder 1999)

8. Chronic LBP
 20% 1st episode of LBP of these cases may develop into chronic LBP,
lasting for at least three months or longer (Weiner and Nordin, 2011;
Pengel et l, 2003; Wang et al, 2012)
 Chronic LBP accounts for three-quarters of the total direct and indirect
costs of medical care and lost productivity associated with LBP (Foumey
et al, 2011)
8/25/2015
8

9. Recurrent LBP
 Recurrent LBP is defined as a new episode after a symptom-free period of 6 months, but not an
exacerbation of chronic low back pain (van Tulder et al, 2004)
 Multifidus and TrA are implicated
 Multifidus recovery is not automatic after resolution of acute low back pain (Hides et al, 1996)
 41 with LBP, 1st episode, unilateral, <3weeks, treated with multifidi and TrA exercise- both groups
improved, mulfidus CSA was more rapid and complete in specific exercise group (Hides et al,
1996)
 Source: Steere 2011
8/25/2015
9

10. Back/Abdominal Muscles
8/25/2015
10

11. 8/25/2015
11
Stabs/Mobs
 Source: Luque-Suárez, 2012

12. Core Stabilizers
 Multifidi
 TrA
8/25/2015
12

13. Transversus abdominis
Source: en.wikipedia.org
8/25/2015
13

14. Multifidi
Sources: coreconcepts.com.sg
8/25/2015
14

15. Precursors for LBP
 Weakness of abdominal and back muscles especially
the back extensors
 Muscular dysfunction in the low back, and abdominal
muscles
 Poor joint flexibility in the back and hamstring are
reported as precursors for LBP (Biering Sørenson, 1984,
Pollock and Wilmore, 1990, Robinson, 1992, Richardson
and Jull, 1995, McArdle et al, 1996,)
8/25/2015
15

16. PT Aims
 Pain
 Function
 Reintegration
 Prevent recurrence
8/25/2015
16

17. PT in LBP
 Modalities
 Exercises
 Treatment protocols
 Self Management
 Common analgesics
8/25/2015
17

18. EVIDENCES for LBP Treatment
 Treatment effects not conclusive
 Exercise remains central to management of LBP of mechanical origin,
long-term
 Self management is encouraged with exercise
(Hayden et al, 2005)
8/25/2015
18

19. Evidences for Treatment
8/25/2015
19

20. Theoretical Basis for Therapeutic Exercise
 SAID Principle: Specific Adaptation to Imposed Demand;
imposed demands must be specific to goals in mind
 FITT: Frequency, Intensity, Time, Type
8/25/2015
20

21. Therapeutic Exercise
Acute
 –Centralization and directional preference exercise versus no exercise
Sub-acute and Chronic
 –Centralization and directional preference exercise
 –Trunk coordination, stabilization
 –Strengthening
 –Endurance
(Delitto, et al. (2012) Clinical Guidelines, J Orthop Sports Phys Ther
8/25/2015
21

22. Therapeutic Exercise
 Diverse
 Flexibility
 Aerobic
 Strengthening
 Endurance
 Schools of thoughts- Cyriax, McKenzie, William Flexion, Maitland, Mulligan
 Postural managements e.g. Cesar Therapy
 Work Hardening
8/25/2015
22

23. Specific/Non Specific Exercise
Specific Exercise:
 Tailored to treat musculoskeletal dysfunctions
Non-specific Exercise:
 Stretching and aerobic conditioning
 Individual
 Group
 Home
8/25/2015
23

24. Flexibility
 Activity which lengthens a muscle while increasing range of motion.
Examples include self-stretch, yoga, Pilates, and chair stretching routines
 Abdominals, hamstrings, quadriceps, hip abductors, gluteals
Sahrmann (2001)
8/25/2015
24

25. Strengthening/Endurance Exercise
 Strengthening exercise is when the body’s muscles work against a force or
weight, contracting repeatedly
 Muscular endurance capabilities of back muscles may be as important as
or even more important than strength in the prevention and treatment of
low back pain (Moffroid (1997)
 Evidences are in literature linking weaknesses of abdominal and back
extensor weakness with low back pain or and its susceptibility in, adults
and children
Holmstrom et al, 1992, Mannion and Dolan, 1994, Luoto et al, 1995, Adegoke
and Babatunde, 2007; Mbada and Ayanniyi, 2008; Johnson et al, 2009
8/25/2015
25

26. Hayden et al 2005
 Meta-analysis of Exercise Strategies for CLBP
Best programs:
 –Individually designed
 –Supervised
 –High-dose v. low-dose
 –Multi-modal
Hayden, Ann Intern Med 2005
8/25/2015
26

27. Hayden et al 2005
 39 trials were identified. There is strong evidence that exercise therapy is
not more effective for acute low back pain than inactive or other active
treatments
 There is conflicting evidence on the effectiveness of exercise therapy
compared with inactive treatments for chronic low back pain
 Exercise therapy was more effective than usual care by the general
practitioner and just as effective as conventional physiotherapy for
chronic low back pain
8/25/2015
27

28. Effect of a Graded Exercise
 A graded exercise intervention emphasizing stabilizing exercises seems to
improve perceived disability and health parameters in short and long
terms in patients with recurrent LBP.
 No such improvement was seen in the longer terms for perceived pain.
 The exercises, by being individually graded, might change self-efficacy
beliefs and thus improve perceived disability
 The exercise intervention seems to reduce the need for recurrent
treatment in long-term
Rasmussen-Barr, Spine, 2009
8/25/2015
28

29. Stabilization
 Stabilizing training compared with manual treatment in sub-acute and CLBP
Short term
 No clear differences between the groups in outcome measures of pain, and
functional disability
Long-term
 Stabilizing training more effective and reduced need for recurrent treatment
period
(Rasmussen-Barr, 2003)
8/25/2015
29

30. Comparison of general exercise, motor control exercise
and SMT manipulative therapy for CLBP
Motor control exercise and spinal manipulative therapy produce slightly better
short-term function and perceptions of effect than general exercise, but not
better medium or long-term effects
Ferreira, Pain, 2007
8/25/2015
30

31. Low Back Pain Exercise and Prevention
 High-quality controlled trials on preventing episodes of back problems:
systematic literature review in working-age adults (Bigos, et al. Spine J, 2009)
 Exercise prevented self-reported BPs in seven of eight trials
 Exercise significantly reduced work absence in three trials
 Stress management, shoe inserts, back supports, ergonomic/ back
education, & reduced lifting programs
8/25/2015
31

32. Low Back Pain Bigos, 2009, cont.
 Trunk strength, endurance, flexibility, stabilization, directional preference
 –5/7 successful programs involved 45–60 min of supervised exercise, twice
a week for 3–12 months
8/25/2015
32

33. Low Back Pain Exercise and Prevention
 Moderate quality evidence that post-treatment exercise programmes can
prevent recurrences of back pain but conflicting evidence was found for
treatment exercise
 Rationale: Post-treatment exercise is about habits. Exercise as a treatment
might or might not help in short time, but won’t necessarily change habits
and therefore future episodes
Cochrane review, 2010
8/25/2015
33

34. 8/25/2015
34

35. Systematic Review
8/25/2015
35

36. 8/25/2015
36

37. 8/25/2015
37
 Effect of Graded Exercise Rasmussen-Barr, Spine, 2009
 •A graded exercise intervention emphasizing stabilizing exercises
seems to improve perceived disability and health parameters in
short and long terms in patients with recurrent LBP.
 •No such improvement was seen in the longer terms for
perceived pain.
 •The exercises, by being individually graded, might change self-
efficacy beliefs and thus improve perceived disability.
 •The exercise intervention seems to reduce the need for recurrent
treatment in long-term.

38. Stabilizing training compared with manual treatment in
sub-acute and CLBP
 Short –term
No clear differences between the groups in the assessed outcome measures;
pain, health status, and functional Disability
 Long-term
Stabilizing training more effective and reduced need for recurrent treatment
periods
Rasmussen-Barr, Man Ther, 2003
8/25/2015
38

39. Exercise Therapy
Exercise therapy is considered as an effective treatment to reduce self-
reported pain and improve the back pain specific functional status of
participants with chronic LBP (Hayden, 2005)
Gerard A. Malanga et al. (2008) argue that once the painful symptoms are
controlled, stretching and strengthening exercises can be initiated
8/25/2015
39

40. 8/25/2015
40
 Core stabilizers
 General exercises

41. 8/25/2015
41
 A successful exercise programme needs to be specific, targeted and
progressive (Hides et al., 2001; Mooney et al., 2001; Prather, 2003;
Zelle et al., 2005
 Physiotherapy management of long term low back pain favours
active low back Treatment programmes involving improving aerobic
fitness, increasing the strength and flexibility of the lumbar
musculature and ensuring lumbar stability (Shiple, 1997)

42. Isolation
 Patients need to develop the ability to recruit the targeted group of
muscles independently of other groups. The initial target is the so called
‘‘inner unit’’ and includes TrA, multifidus and pelvic floor muscles
8/25/2015
42

43. Combination
 the second stage those muscles are recruited in various combinations to
develop strength and endurance.
 Diverse exercises are introduced whilst maintaining controlled contraction
of the TrA, multifidus, pelvic floor

 Exercise should be slow, measured initially, and become faster as control
and graduated
8/25/2015
43

44. Function
 In the third stage the patient progresses to functional activities; ADL, work
return, sport or physical requirements
 It requires tailoring the exercise programme to patients’ needs and goals,
whilst maintaining guiding principle
(Saunders et al., 2005)
8/25/2015
44

45. Stretching Left quadratus luborum

8/25/2015
45

46. 8/25/2015
46

47. Lumbar Stability
 Stability is provided in a coordinated manner by the muscles, lumbar spine
and neurological systems
8/25/2015
47

48. 8/25/2015
48
Exercises for Core Stabilizers

49. 8/25/2015
49

50. 8/25/2015
50

51. 8/25/2015
51

52. 8/25/2015
52

53. 8/25/2015
53

54. 8/25/2015
54

55. 8/25/2015
55

56. 8/25/2015
56

57. 8/25/2015
57

58. 8/25/2015
58

59. 8/25/2015
59

60. 8/25/2015
60

61. 8/25/2015
61

62. 8/25/2015
62

63. 8/25/2015
63

64. 8/25/2015
64

65. 8/25/2015
65

66. CONCLUSION
 Effective management of LBP that must overcome the bane of its
management must begin at the acute phase
 Recognizing the role of the core stabilizers in prevention of recurrence is
crucial to management success
 Exercises of diverse nature are effective in combating chronicity
8/25/2015
66

67. Standardized Outcomes in Low Back Pain
 Generic: NPS, VAS, McGill Pain Questionnaire, FABQ, Pain Catastrophizing
Scale
 Specific: Oswestry, Roland Morris, Quebec Back Pain Disability Scale, Back
Pain Functional Scale, Start Back, McKenzie’s
8/25/2015
67

68. References
 Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of a clinical
prediction rule for determining which patients with low back pain will
respond to a stabilization exercise program. Archives of Physical Medicine
&amp;amp;amp;amp;amp;amp;amp;amp;amp; Rehabilitation.
September 2005;86(9):1753-1762
 C. Richardson et al.; Therapeutic exercise for lumbopelvic stabilization: A
motor control approach for the treatment and prevention of low back
pain; p. 177-178, 180-181, 186; Churchill Livingstone; 2004 (Level of
evidence5
 Panjabi, M.M. (1992): The Stabilizing system of the spine part 1: Function,
dysfunction adaptation and enhancement. Journal of Spinal Disorders, 5,
383-389
8/25/2015
68

69. References
 Arab A, Behbahani R, Lorestani L, Azari A. Assessment of pelvic floor muscle function in women
with and without low back pain using transabdominal ultrasound. Manual Therapy. June
2010;15(3):235-239.
 Smith M, Russell A, Hodges P. Do incontinence, breathing difficulties, and gastrointestinal
symptoms increase the risk of future back pain?. Journal of Pain. August 2009;10(8):876-886.
 Smith M, Russell A, Hodges P. Do incontinence, breathing difficulties, and gastrointestinal
symptoms increase the risk of future back pain? Journal of Pain. August 2009;10(8):876-886.
 Grewar H, McLean L. The integrated continence system: a manual therapy approach to the
treatment of stress urinary incontinence. Manual Therapy. October 2008;13(5):375-386.
 Mohseni-Bandpei M, Rahmani N, Behtash H, Karimloo M. The effect of pelvic floor muscle
exercise on women with chronic non-specific low back pain. Journal of Bodywork
&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Movement Therapies.
2011;15(1):75-81.
 Christie C, Colosi R. Paving the way for a healthy pelvic floor. IDEA Fitness Journal. May
2009;6(5):42-49.
8/25/2015
69

70. References
 Pool-Goudzwaard A, Slieker ten Hove M, Stoeckart R, et al. Relations
between pregnancy-related low back pain, pelvic floor activity and
pelvic floor dysfunction. International Urogynecology Journal And Pelvic
Floor Dysfunction. November 2005;16(6):468-474.
 Smith M, Russell A, Hodges P. Disorders of breathing and continence have
a stronger association with back pain than obesity and physical activity.
Australian Journal of Physiotherapy. March 2006;52(1):11-16.
8/25/2015
70

71. 8/25/2015
71