TREATMENT PROTOCOL LOWER BACK PAIN
Based on international guidelines for the management thereof
Supporting Literature;
o EU physiotherapy guidelines for lower back pain
o Australian Guidelines on Yellow Flags
o Cognitive Behavioural Guidelines for Physio and Occupational Therapists
Triage:
1.
2.
3.
4.
the acute back
sub-acute back
chronic back
red and yellow flags
1. The Acute Back:
80% of any population will experience LBP during their lives. Most episodes are short lived and
self-resolving. 20% of the above will become chronic back pain, which is classified as back pain
lasting longer than 3 months.
Of major importance is the identification of red and yellow flags on initial and follow up
assessments by the therapist. The presence thereof will greatly influence the choice of
management and treatment techniques applied.
Initial assessment of the acute back may be restricted if the nature of pain is such that it is easily
exacerbated (high ‘SIN’). A thorough subjective must be done, and questions including red and
yellow flags, as well as onset, previous history, mechanism of injury and type/location of pain
should be asked.
Emphasis is placed on reduction in pain through advice and gentle movement and referral to
relevant sections should any flags be identified. It is important that the client is educated on the
following:
- back pain is usually self limiting and will recover with appropriate management
- bedrest and inactivity should be discouraged- no more than 2 days maximum!- as this is
likely to lead to poor functional outcome due to small intervertebral muscle degeneration
and psychological fear avoidance.
- Early return to original activities- with adaptations- is required. (although in our case, a
short break from heavy work such as ploughing and lifting 25L water is a good idea)
Subtypes:
a. traumatic
b. insidious with uni-directional movement limitation
c. insidious and non-specific
a. Traumatic
These can usually be classified into disc injury and multiple facet joint involvement.
Distinguishing between the two can be challenging (see following notes). Beware of releasing
too much soft tissue restriction in one session- it can exacerbate symptoms. Mobilization can
be done- try to start on contralateral side: you need to mobilize into the maximum grade
possible (usually a grade 3) for effect. Grade 1 and 2 on the affected side is not usually worth
it.
The client can be taught self traction (knees on a chair), sleeping positions, gentle knee rolling
and pelvic tilts. Encourage log rolling and get the client to demonstrate certain functional
movements (dressing, washing, moving in and out of one position to another) and correct them
in each. Try an avoid issuing back braces as much as possible, and ESPECIALLY if there are
any signs of yellow flags.
Screen for flags, refer to Yvonne if yellow flags present.
Mobilize.
b. insidious with uni-directional movement limitation
It is rare to find a restriction in one direction only- usually there is a predominant restriction with
secondary restrictions in other directions. Usually facet involvement is the cause. Use the
following method to determine which structures are gapped/compressed and
stretched/shortened so that you can chose the best mobilization for the restriction:
anterior
left
right
Posterior
The trick is to start in the position furthest away from the most painful position. For instance, if
extension/lat flex left is the worst, start the person in flex/lat flex right, slowly moving the person
towards their most painful position with each treatment. If the person is not very irritable, you
can start in a more aggravating position. If very irritable, start in the position furthest away. If
the problem is a stiff facet joint, I would mobilize on it. If the problem is a nerve root
sensitization, I would mobilize on the contralateral side. Remember what plane the facets lie at
in Cx (45) vs Tx (60) vs Lx (90)- if you are doing a unilateral pa, are you compressing what
should be gapped? If you choose rotations, few clients relax for it to be effective- rather put into
crook lie supine (with a towel under buttocks if you want to target lower lumber) and do active
rotations, or prone and rotate by stabilizing the Sx and rotating the hemipelvis posteriorly.
The most important consideration is:
Why does this person have a movement limitation?
Usually you will find a considerable amount of asymmetry in their posture which can explain
the movement deficit. You will need to address this otherwise it is pointless mobilizing them.
Make sure you lift ladies skirts- many an old polio case has been mistaken for a simple pelvic
rotation! Think globally, and get them to move through various postures- you will be able to
pick up rotations/stuck SIJs/poor unilateral hip stabilities/tight lateral structures/poor segmental
control by just observing.
Start in closed kinetic chain as soon as possible, and work globally (pilates doesn’t work here,
and the link between the HEP and the ADL doesn’t happen). Use your Bobath principles- they
are useful and activity related- and sling concepts.
Again, always screen for red and yellow flags.
Correct asymmetry
c. insidious and non-specific
Usually these are your instabilities and/or your yellow flags. These are the ladies with no
consideration for their spine whatsoever- usually found to hinge badly around L3/4 (unisegmental instability), with consequent stiffness above and below these segments and
degeneration as a result (anterior sway or lordotics). Briefly mobilize the segments above and
below if you want, but these people need to learn how to maintain a neutral spine, and then
how to maintain a neutral spine during lower and upper limb activity. Easier said than done,
and much visual feedback using cellphone cameras, the spine model and biofeedback can be
done. You need to link it to ADL positions as soon as possible. Occasionally we have multilevel instabilities- treat similarly, but without mobilization. Screen for red and yellow flags.
Stabilize.
2. The Sub-acute Back:
This is usually the time they eventually get to rehab- it is getting better though! Strict screening
for flags- we still have to catch them and refer! The same categories can be applied as above,
but patients will usually be of lower SIN and thus a more aggressive treatment can be done.
Again, check GLOBALLY for reasons for lower back pain- you will find them through
observation! Emphasis must be placed on HEP and activities, with kinetic handling per activity.
Self management of pain is essential.
3 & 4. The chronic back and yellow flags:
I have grouped these because there are very few patients with chronic back pain and a
physiological reason only. Much can be achieved in mobility through correct exercises and
activities rather than OMT, and it is easier to grade, steers away from passive treatment and
promotes self management. Please note- just because there are yellow flags does NOT mean
you do not investigate and treat the underlying pathology!!!!!! Chronic backs need just as much
observation, otherwise the exercises given will not be specific and will not support the activity
goals set by the patient.
If yellow flags present, refer to Yvonne immediately (see screening tool). The earlier you
address these, the better the functional outcome and the less likely they are to become a
chronic back. The basis for addressing yellow flags is the following:
- check for anxiety, depression, fear avoidance (of movement- usually in traumatic backs
rather than insidious onset), inappropriate pain beliefs, poor social support from family and
or partner, DG/RAF seeking focus, poor incentive to continue/return to work (ie, ADL
tasks) and catastrophizing
-
-
-
education that some pain during activities is not bad, and that activities must be resumed
early, even if the pain has not disappeared entirely. Move away from the ‘broken machine’
explanation- it sometimes becomes a crutch
avoid assistive devices such as braces and educate on medicating wisely (don’t overdo)
preferably try to find out the root cause of the distress with the patient. Decide together on
functional goals (activities) that should be achieved in a specific timeframe, regardless of
pain- these should take the physical and emotional barriers into account. Stick to these
goals. Goals should be specific, measurable, activity based, realistic (achievable) and
have a time frame attached.
Do not ask about pain- rather concentrate on function
Very important is that the person learns pacing. It is important that they do not experience
flare-ups which will result in periods of inactivity and thus deconditioning and an inability to
reach goals. The general rule is- find your maximum tolerance for one activity or position,
then try to maintain daily participation of 50-80% of this maximum tolerance. Slowly
increase this amount.
If the person is literate, they can be asked to keep a diary.
Steer away from passive treatments (like massage, electrotherapy and OMT) and keep
patient involvement in treatment (exercises as well as goal setting) at a maximum. Teach
relaxation and self management (hot packs, positioning) techniques.