Saanichton Physical Therapy Blog

Physiotherapy for Back Pain recommendations

Physiotherapy for Back Pain recommendations

Physiotherapy for Back Pain recommendations:

Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-A57. [327 references] PubMed External Web Site Policy

Levels of evidence (I–V) and grades of recommendation (A–F) are defined at the end of the “Major Recommendations” field.

Risk Factors

Current literature does not support a definitive cause for initial episodes of low back pain. Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain. (Grade of Recommendation B)

Clinical Course

The clinical course of low back pain can be described as acute, subacute, recurrent, or chronic. Given the high prevalence of recurrent and chronic low back pain and the associated costs, clinicians should place high priority on interventions that prevent (1) recurrences and (2) the transition to chronic low back pain. (Grade of Recommendation E)

Diagnosis/Classification

Low back pain, without symptoms or signs of serious medical or psychological conditions, associated with clinical findings of (1) mobility impairment in the thoracic, lumbar, or sacroiliac regions, (2) referred or radiating pain into a lower extremity, and (3) generalized pain, is useful for classifying a patient with low back pain into the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: low back pain, lumbago, lumbosacral segmental/somatic dysfunction, low back strain, spinal instabilities, flatback syndrome, lumbago due to displacement of intervertebral disc, lumbago with sciatica, and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category of low back pain (b28013 Pain in back, b28018 Pain in body part, specified as pain in buttock, groin, and thigh) and the following corresponding impairments of body function:

  • Acute or subacute low back pain with mobility deficits (b7101 Mobility of several joints)
  • Acute, subacute, or chronic low back pain with movement coordination impairments (b7601 Control of complex voluntary movements)
  • Acute low back pain with related (referred) lower extremity pain (b28015 Pain in lower limb)
  • Acute, subacute, or chronic low back pain with radiating pain (b2804 Radiating pain in a segment or region)
  • Acute or subacute low back pain with related cognitive or affective tendencies (b2703 Sensitivity to a noxious stimulus, b1522 Range of emotion, b1608 Thought functions, specified as the tendency to elaborate physical symptoms for cognitive/ideational reasons, b1528 Emotional functions, specified as the tendency to elaborate physical symptoms for emotional/affective reasons)
  • Chronic low back pain with related generalized pain (b2800 Generalized pain, b1520 Appropriateness of emotion, b1602 Content of thought)

The ICD diagnosis of lumbosacral segmental/somatic dysfunction and the associated ICF 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:

  • 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

The ICD diagnosis of lumbosacral segmental/somatic dysfunction and the associated ICF diagnosis of subacute low back pain with mobility deficits are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Subacute, 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

The ICD diagnosis of spinal instabilities and the associated ICF diagnosis of acute low back pain with movement coordination impairments are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Acute exacerbation of recurring low back pain and associated (referred) lower extremity pain
  • Symptoms produced with initial to mid-range spinal movements and provocation of the involved lumbar segment(s)
  • Movement coordination impairments of the lumbopelvic region with low back flexion and extension movements

The ICD diagnosis of spinal instabilities and the associated ICF diagnosis of subacute low back pain with movement coordination impairments are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Subacute exacerbation of recurring low back pain and associated (referred) lower extremity pain
  • Symptoms produced with mid-range motions that worsen with end-range movements or positions and provocation of the involved lumbar segment(s)
  • Lumbar segmental hypermobility may be present
  • Mobility deficits of the thorax and pelvic/hip regions may be present
  • Diminished trunk or pelvic-region muscle strength and endurance
  • Movement coordination impairments while performing self-care/home management activities

The ICD diagnosis of spinal instabilities and the associated ICF diagnosis of chronic low back pain with movement coordination impairments are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Chronic, recurring low back pain and associated (referred) lower extremity pain
  • Presence of 1 or more of the following:
    • Low back and/or low back–related lower extremity pain that worsens with sustained end-range movements or positions
    • Lumbar hypermobility with segmental motion assessment
    • Mobility deficits of the thorax and lumbopelvic/hip regions
    • Diminished trunk or pelvic-region muscle strength and endurance
    • Movement coordination impairments while performing community/work-related recreational or occupational activities

The ICD diagnosis of flatback syndrome, or lumbago due to displacement of intervertebral disc, and the associated ICF diagnosis of acute low back pain with related (referred) lower extremity pain are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Low back pain, commonly associated with referred buttock, thigh, or leg pain, that worsens with flexion activities and sitting
  • Low back and lower extremity pain that can be centralized and diminished with positioning, manual procedures, and/or repeated movements
  • Lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility, and clinical findings associated with the subacute or chronic low back pain with movement coordination impairments category are commonly present

The ICD diagnosis of lumbago with sciatica and the associated ICF diagnosis of acute low back pain with radiating pain are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Acute low back pain with associated radiating pain in the involved lower extremity
  • Lower extremity paresthesias, numbness, and weakness may be reported
  • Symptoms are reproduced or aggravated with initial to mid-range spinal mobility, lower-limb tension/straight leg raising, and/or slump tests
  • Signs of nerve root involvement (sensory, strength, or reflex deficits) may be present

It is common for the symptoms and impairments of body function in patients who have acute low back pain with radiating pain to also be present in patients who have acute low back pain with related (referred) lower extremity pain.

The ICD diagnosis of lumbago with sciatica and the associated ICF diagnosis of subacute low back pain with radiating pain are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Subacute, recurring mid-back and/or low back pain with associated radiating pain and potential sensory, strength, or reflex deficits in the involved lower extremity
  • Symptoms are reproduced or aggravated with mid-range and worsen with end-range lower-limb tension/straight leg raising and/or slump tests

The ICD diagnosis of lumbago with sciatica and the associated ICF diagnosis of chronic low back pain with radiating pain are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Chronic, recurring mid-back and/or low back pain with associated radiating pain and potential sensory, strength, or reflex deficits in the involved lower extremity
  • Symptoms are reproduced or aggravated with sustained end-range lower-limb tension/straight leg raising and/or slump tests

The ICD diagnosis of low back pain/low back strain/lumbago and the associated ICF diagnosis of acute or subacute low back pain with related cognitive or affective tendencies are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Acute or subacute low back and/or low back–related lower extremity pain
  • Presence of 1 or more of the following:
    • Two positive responses to Primary Care Evaluation of Mental Disorders for depressive symptoms
    • High scores on the Fear-Avoidance Beliefs Questionnaire and behavior consistent with an individual who has excessive anxiety or fear
    • High scores on the Pain Catastrophizing Scale and cognitive processes consistent with individuals with high helplessness, rumination, or pessimism about low back pain

The ICD diagnosis of low back pain/low back strain/lumbago and the associated ICF diagnosis of chronic low back pain with related generalized pain are made with a reasonable level of certainty when the patient presents with the following clinical findings:

  • Low back and/or low back–related lower extremity pain with symptom duration for longer than 3 months
  • Generalized pain not consistent with other impairment-based classification criteria presented in these clinical guidelines
  • Presence of depression, fear-avoidance beliefs, and/or pain catastrophizing

(Grade of Recommendation B)

Differential Diagnosis

Clinicians should consider diagnostic classifications associated with serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when (1) the patient’s clinical findings are suggestive of serious medical or psychological pathology, (2) the reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of these guidelines, or (3) the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Grade of Recommendation A)

Examination

Outcome Measure

Clinicians should use validated self-report questionnaires, such as the Oswestry Disability Index and the Roland-Morris Disability Questionnaire. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in a patient’s status throughout the course of treatment. (Grade of Recommendation A)

Activity Limitation and Participation Restriction Measures

Clinicians should routinely assess activity limitation and participation restriction through validated performance-based measures. Changes in the patient’s level of activity limitation and participation restriction should be monitored with these same measures over the course of treatment. (Grade of Recommendation F)

Interventions

Manual Therapy

Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain. (Grade of Recommendation A)

Trunk Coordination, Strengthening, and Endurance Exercises

Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post–lumbar microdiscectomy. (Grade of Recommendation A)

Centralization and Directional Preference Exercises and Procedures

Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. (Grade of Recommendation A)

Flexion Exercises

Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain. (Grade of Recommendation C)

Lower-Quarter Nerve Mobilization Procedures

Clinicians should consider utilizing lower-quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain. (Grade of Recommendation C)

Traction

There is conflicting evidence for the efficacy of intermittent lumbar traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or in patients with chronic low back pain. (Grade of Recommendation D)

Patient Education and Counseling

Clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that (1) promote extended bed-rest or (2) provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain. Patient education and counseling strategies for patients with low back pain should emphasize (1) the promotion of the understanding of the anatomical/structural strength inherent in the human spine, (2) the neuroscience that explains pain perception, (3) the overall favorable prognosis of low back pain, (4) the use of active pain coping strategies that decrease fear and catastrophizing, (5) the early resumption of normal or vocational activities, even when still experiencing pain, and (6) the importance of improvement in activity levels, not just pain relief. (Grade of Recommendation B)

Progressive Endurance Exercise and Fitness Activities

Clinicians should consider (1) moderate- to high-intensity exercise for patients with chronic low back pain without generalized pain, and (2) incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain. (Grade of Recommendation A)

Definitions:

Levels of Evidence

Individual clinical research articles were graded according to criteria described by the Centre for Evidence-Based Medicine, Oxford, United Kingdom.

  1. Evidence obtained from high-quality diagnostic studies, prospective studies, or randomized controlled trials
  2. Evidence obtained from lesser-quality diagnostic studies, prospective studies, or randomized controlled trials (e.g., weaker diagnostic criteria and reference standards, improper randomization, no blinding, <80% follow-up)
  3. Case-controlled studies or retrospective studies
  4. Case series
  5. Expert opinion

Grades of Recommendation

The overall strength of the evidence supporting recommendations made in these guidelines will be graded according to guidelines described by Guyatt et al, as modified by MacDermid and adopted by the coordinator and reviewers of this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to demonstrate biological or biomechanical plausibility.

Grades of Recommendation Strength of Evidence
A Strong evidence A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study
B Moderate evidence A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation
C Weak evidence A single level II study or a preponderance of level III and IV studies including statements of consensus by content experts support the recommendation
D Conflicting evidence Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies
E Theoretical/foundational evidence A preponderance of evidence from animal or cadaver studies, from conceptual models/principles or from basic sciences/bench research support this conclusion
F Expert opinion Best practice based on the clinical experience of the guidelines development team