The use of an eclectic approach for the treatment of low back pain: a case study.

Physical therapy procedures are among the many forms of treatment that are used for the rehabilitation of people who have low back pain (LBP).[1-10] Patients being treated for LBP may comprise as much as 35% of the population in outpatient physical therapy clinics.[11] Despite the large number of people receiving physical therapy for LBP, the efficacy of most of these treatments, including the use of manual therapy, remains controversial.[12-15]

The establishment of the efficacy of manual therapy techniques (see article by Di Fabio in this issue) remains difficult. Quite often the emphasis of the manual therapy examination has been on palpating "movement,"[10,16] identifying "positional faults,"[16,17] or observing the "quality of movement."[18] Less emphasis has been placed on identifying impairments and forming testable hypotheses that relate these impairments to disabilities. [19,20] Impairment has been defined by Jette as "any loss or abnormality of psychologic, physiologic, or anatomic structure within a specific organ or system of the body."[19](p968) According to Jette, a disability is "any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being."[19](968) The purposes of this case report are (1) to describe an examination approach that relates identification of an impairment to a disability and (2) to describe an eclectic treatment approach for an individual with LBP.

Identification of Patient's Problem

The patient was a 22-year-old male college student-athlete who competed internationally as a pole vaulter. At the time of his initial physical therapy evaluation, he complained of chronic central midlumbar pain and stiffness, which had impaired his ability to perform the "take-off phase" of pole vaulting for the previous year. Despite this problem, he had continued to train and compete. In the 2 weeks prior to his initial physical therapy visit, the pain and stiffness had become more disabling and had forced him to stop pole vaulting. During his initial visit, he stated that he had a competition in 3 weeks and that his goal was to compete.

Interview Data

The patient stated that his pain was in the center of the middle portion of his low back (ie, the midlumbar spine corresponding to the L3-4 and L4-5 spinal levels). His pain was not present at rest but was noticeable during the take-off phase of pole vaulting. He also stated that he felt "stiff " when he attempted to extend and rotate his spine during the take-off phase. For the purpose of this case report, the "take-off phase" will be defined as that period which the pole vaulter has planted the pole in the "box" and is beginning the vault.21 The only other time that the patient reported being aware of his symptoms was when he sat in one position for more than 45 minutes. This was a problem for him because he frequently was required to sit for long periods while in class and when traveling.

The patient first noticed this pain and stiffness approximately 1 year prior to his initial physical therapy visit. He did not recall any episode of trauma. The pain followed an increase in the duration of his daily training program. The magnitude of his symptoms gradually increased for several weeks. Despite the symptoms when he was vaulting and during prolonged sitting, he reported that he was able to continue training and to compete during this time. Approximately 1 month following the onset of LBP and stiffness he began receiving treatments of chiropractic manipulation. A description of these manipulative procedures is not available. The patient stated that following these treatments, he was still aware of his pain and stiffness, but his symptoms were less intense. This reduction of symptoms, however, lasted only for 24 hours following each treatment, after which his pain and stiffness returned to the pretreatment level. After approximately 10 chiropractic sessions over a 2-month period, he discontinued this treatment.

Over the next 3 months, the patient received approximately 10 ultrasound treatments to the lumbar spine at the athletic training facility at the University of New Mexico (Albuquerque, NM) and 1 treatment of acupuncture from a licensed acupuncturist in the Albuquerque area. These treatments were reported to result in short-term (less than 24 hours) reduction of his pain and stiffness. Four days prior to his initial physical therapy visit, he consulted an orthopedic surgeon. At this time, radiographs of the lumbar spine were obtained and interpreted by the orthopedist as being normal. A diagnosis of "musculoskeletal strain" was made by the orthopedist, who then referred the patient to physical therapy.

The patient's medical history revealed no serious illness or injuries. He had no previous history of activity-limiting spinal problems. He did not complain of pain, muscular weakness, or sensory disturbance in the buttocks or lower extremities. He was taking no medications.

A problem statement was developed at this time to relate the patient's disability to potential impairments. The patient's complaints were most noticeable during the take-off phase of pole vaulting. This activity requires that the individual assume a position of spinal extension, with side-bending and rotation of the trunk to the right.[21] The central location of the patient's pain and stiffness suggested that "local" limitation of spinal movement,[16] (ie, limited motion in the midlumbar spinal segments) may have been related to his inability to pole vault. Thus, the initial problem statement was that the patient's midlumbar symptoms were associated with an abnormality of spinal motion, which prevented him from pole vaulting, and that his tendency to sit for long periods contributed to his midlumbar symptoms.

Physical Examination

No obvious deformities or asymmetries of the spine or lower extremities were observed while the patient was standing. I assessed the symmetry of height of the iliac crests by kneeling behind the standing patient and using the radial aspect of my hands to palpate the iliac crests. The iliac crests appeared to be level on the transverse plane. From this, I inferred that the leg lengths were equal.[16,18,22,23] The patient's active range of motion (AROM) of the trunk on the sagittal plane was assessed as follows. I stood at the right side of the patient and identified the L5-S1 interspace with my left little finger. I then placed my left index finger approximately 10 cm superior to this on the spinal midline. The standing patient was asked to slowly bend forward and then backward from the waist as far as he could and to stop if he felt discomfort. I maintained digital contact with the patient's spine in an attempt to grossly identify the displacement of the spinous processes with respect to one another. This technique has been described by Schober[24] as a qualitative procedure for the assessment of sagittal-plane spinal motion. Forward trunk bending was not painful and appeared to be normal, as determined by my observation. When backward trunk bending, the patient stated that he stopped prematurely because of pain and stiffness. The assumption was therefore made that the patient was not able to perform his "normal" spinal extension.

The patient's AROM of the trunk on the frontal plane was assessed as follows. To observe the motion of lumbar side-bending, I stood approximately 0.9 m (3 ft) behind the standing patient. The patient was instructed to bend his trunk as far as he could to the right while keeping his knees straight and to stop if he felt discomfort. Following this maneuver, he was requested to perform the same motion to the left. When side-bending to the right, the patient stated that he stopped prematurely because of pain. He did not complain of pain or stiffness when he performed side-bending to the left. Thus, I made the assumption that the patient was not able to perform his "normal" right side-bending.[10,18,25-27]

The patient's AROM of the trunk on the transverse plane was assessed as follows. To observe the motion of trunk rotation, I stood approximately 0.9 m in front of the sitting patient. The patient was instructed to turn his trunk as far as he could to the right and to stop if he felt discomfort. Following this maneuver, he was requested to perform the same motion to the left. When rotating his trunk to the right, the patient stated that he stopped prematurely because of pain. He did not complain of pain or stiffness when he performed rotation of the trunk to the left. Thus, I made the assumption that the patient was not able to perform his "normal" trunk rotation to the right.[10,18,25-27]

In an attempt to evaluate the activity that most elicited the patient's symptoms (ie, to relate the impairment of abnormal spinal motion to the disability of being unable to pole vault), the patient was asked to assume the position of the trunk that was required during the take-off position. This position was trunk extension, with rotation and side-bending to the right. This position corresponded to the "quadrant position" described by Maitland[10] and Edwards.[28] These authors have described three-dimensional or combined motions as useful for identifying impairment of spinal motion. The patient stated that he was more aware of his pain and stiffness while attempting to assume this position than he was during the previous portion of the physical examination. He also stated that he felt that his motion toward the quadrant position was less than was needed to perform the take-off phase of pole vaulting. When the patient performed spinal extension, with rotation of the trunk and side-bending to the left, he stated that he felt no pain or stiffness.

Following the evaluation of spinal motion and symmetry of leg lengths, the patient assumed the supine position. The following movements were performed by the patient: hip flexion, hip extension, hip medial (internal) rotation, hip lateral (external) rotation, knee flexion, knee extension, ankle dorsiflexion, and ankle plantar flexion. The patient's AROM was normal, as defined by Magee[25] and Hoppenfeld.[26] The straight-leg-raising (SLR) test was performed as described by Hoppenfeld.[26] The patient's SLR was 90 degrees bilaterally, and no pain was elicited during this procedure. Manual muscle testing was performed using the "break test" by requesting the patient to perform each of the eight movements against manual resistance that I applied.[29] No muscular force deficits were noted in the lower extremities. I performed sensory testing, using a light brushing motion of my hands over the dermatomes that correspond to L2 through S2, to determine the presence and symmetry of the patient's light touch sensation.[25,26] There were no apparent sensory deficits to light touch. The patellar tendon and Achilles tendon reflexes were assessed using a reflex hammer and were found to be normal bilaterally.[25,26]

Several tests were performed in an attempt to rule out hip or sacroiliac joints as sources of the patient's problem. The Patrick's (FABER or Figure-Four) test was not painful.[25,26] The anterior and posterior sacroiliac distraction maneuvers were not painful.[17,27] The Thomas test yielded negative results.[6,25,27,29]

Palpation of the posterior trunk was performed as follows. The patient lay on a treatment table in the prone position. The paravertebral soft tissues were examined using fingertip palpation. Pain was elicited with palpation unilaterally, 1 cm to the right of the spinal segmental levels of L2-4. The spinous processes of the lumbar spine were palpated using the techniques of posterior-anterior (P-A) and transverse pressure application described by Maitland.[10] Pain was elicited when grade IV P-A pressures were applied to the spinous processes of L2-4. According to Maitland, a grade IV maneuver is "a tiny-amplitude movement at the limit of range."[10](p85) Pain was also elicited when grade IV P-A transverse pressures were applied to the left side of the spinous processes of L2-4. When performing these maneuvers, it was my opinion that the available motion at the spinal segments of L2-3 and L3-4 was less than normal.

Treatment

Based on the patient history and examination, I hypothesized that the patient had stiffness or "hypomobility" of the spinal motion segments of L2-3 and L3-4.[10,16,18] According to Stoddard,[16] hypomobility may be suspected when a subject complains of stiffness or pain when a joint is forcibly moved. Using a qualitative assessment (ie, my subjective sense of less than normal motion of these segments), a hypothesis was generated that hypomobility and pain were preventing the patient from achieving an adequate trunk AROM to perform the take-off phase of pole vaulting. A second hypothesis was that the patient's report of frequent prolonged sitting in an unsupported position was contributing to his complaint of LBP when sitting for greater than 45 minutes.

Based on these hypotheses, the following goals and strategies were formulated. These strategies were implemented at the time of the patient's initial visit.

The first goal was to restore the patient's ability to perform lumbar backward bending when standing without perceiving pain or stiffness. The strategies used to achieve this goal were as follows. Initially, I applied P-A pressures to the spinous processes of L2-4.[10] This technique has been suggested as a means of increasing motion and decreasing pain.[10,16] Pressure was applied in an oscillating fashion (2-3 oscillations per minute), as described by Maitland.[10] The magnitude of pressure was the maximum that could be applied by the examiner without eliciting the patient's pain (grade II). This technique was performed for two repetitions of approximately 90 seconds each.

Following oscillations, the patient was instructed to perform the lumbar extension exercises described by McKenzie[3] as "prone press-ups" for 10 repetitions, five times a day. This exercise has been advocated by McKenzie as useful for what he has classified as a dysfunction syndrome. According to McKenzie, a patient with a dysfunction syndrome of the lumbar spine will have limited spinal motion in one or more directions and will complain of pain when at the end of the available motion. The prone press-up, therefore, would be an appropriate exercise for the patient to perform following the mobilization treatments and as a home exercise.

The second goal was to restore the patient's ability to perform his normal, pain-free lumbar backward bending combined with right trunk rotation and side-bending (ie, assume the right quadrant position). To achieve this goal, the patient had to assume the right quadrant position without perceiving pain or stiffness. The strategies for achieving this goal were as follows. The examiner applied transverse pressure to the right side of the spinous processes of L2-4. Maitland[10] hypothesizes that this procedure separates the joint surfaces on the painful side and is presumably useful for decreasing pain and increasing motion. Two repetitions of 90 seconds each were performed. The patient was then instructed to perform 10 repetitions of standing trunk rotation to the right, 10 times daily.

The third goal was to modify the patient's habitual sitting position. To achieve this goal, the patient had to be able to sit for 50 minutes without perceiving LBP. Fifty minutes was chosen because it corresponded to the time required for the patient to sit during his university classes. The patient was given a lumbar roll and instructed to use it behind the low back whenever he was sitting.[9] He was also instructed to avoid sitting for longer than 1 hour, regardless of his symptoms.

The final goal was for the patient to return to pole vaulting. To achieve this goal, the patient had to perform his desired day's training without the perception of pain and stiffness during training and for at least 48 hours after training. The strategy was to begin working toward this goal when goals 1 and 2 were achieved. The progression of the patient's performance when pole vaulting (ie, attempted vaulting heights, equipment modification, and technique) was to be decided by the patient's coaches.

Results of Treatment

The patient's second physical therapy session was conducted 4 days after the initial treatment. At that time, he stated that he had very little pain when he attempted to rotate and side-bend his trunk to the right while in a position of trunk extension (ie, the right quadrant position). He stated that he still perceived "mild stiffness." He had been performing his exercises as instructed and was using his lumbar roll when he was sitting. He had not vaulted during this period.

A reexamination using the procedures described previously suggested that the original hypotheses and treatment program were correct. I considered the patient's spinal motion to be normal, and the patient was able to assume the quadrant position. When I passively moved the patient into the end of the available motion (over-pressure) of the right quadrant position, however, he complained of pain. Based on the patient's increased spinal motion and decreased pain, a more vigorous application of the joint mobilization techniques was indicated.[10] At that time, I applied pressure in a P-A direction using short-amplitude oscillations at the end of the palpable anterior displacement (grade IV) of the spinous processes of L2-4.[13] Transverse pressure (grade IV) was applied in the following fashion. I stood on the right side of the supine patient. Using the palmar surface of my right thumb, I palpated the right lateral surface of the spinous process of L2. I then held the patient's right thigh with my left hand. The right hip was passively abducted to the end of its available range of motion. I then held my right thumb against the spinous process of L2 and applied gentle overpressure to the right thigh in a short-amplitude oscillating manner. This maneuver resulted in passive side-bending to the right of the lumbar spine. Two repetitions of 90 seconds each were performed. This procedure was then repeated at L3 and L4. At the end of this session, the patient reported full, pain-free lumbar extension when combined with right rotation and right side-bending. The patient was instructed to continue performing the prone press-up exercises and to perform trunk rotation to the right when standing for 10 repetitions, 10 times daily.

Goals 1 and 2 had been achieved; therefore, the patient was instructed to begin vaulting with the close supervision of his coaches. The patient did not return for outpatient treatment. In telephone conversations I had with the patient 1 week and 1 month later, however, he reported that he was symptom-free and that he was pleased with his ability to pole vault, He competed successfully in his meet.

Discussion

The patient's status was known for only 1 month following this treatment. This is not a sufficient amount of time to determine the long-term effectiveness of the treatment procedures described in this case study. It is noteworthy, however, that this period was the longest time that patient had reported no pain or stiffness in the 1-year period prior to receiving this treatment. It is also noteworthy that he reported that he was able to train and compete without being aware of a back problem.

Several different types of treatment (ie, joint mobilization, exercise, use of a lumbar roll) were used for this patient. Thus, it is difficult to determine the relative effectiveness of each type of treatment. I believe that although the joint mobilization procedures may have been useful for reducing pain and restoring motion, the critical factor in the favorable outcome reported by this patient was his behavioral changes.30 The patient's behavioral changes included the frequent performance of extension exercises and the "correction" of his habitual sitting posture. A careful review of the patient's daily stretching program prior to beginning his physical therapy sessions revealed an absence of spinal extension stretching exercises. When not training and competing, this patient spent a large amount of time sitting. The patient reported that much of this sitting was in a position with the spine flexed. This chronic "poor posture" has been theorized by McKenzie[3] and others[6,9] to predispose a person to chronic stiffness of spinal extension. This may account for the lack of long-term reduction of symptoms during this patient's previous course of manipulative chiropractic) treatment.

In addition to identifying an eclectic treatment approach, the purpose of this case report was to discuss an examination approach that related an impairment to a disability. In this presentation, the patient's impairment was painful stiffness of spinal motion, whereas the patient's disability was the inability to pole vault.[19] Hypotheses were formulated.[20] These hypotheses were tested by administering a treatment approach that attempted to correct the impairment (ie, restore full, pain-free motion of the spine). The primary goal of the treatment, however, was to eliminate the disability (ie, to the allow the patient to return to practice and competition). Although this thought process may seem obvious, it may not always occur, Evaluation procedures that are associated with specific treatment strategies may be problematic.20 In many manual therapy evaluative approaches, a great emphasis is placed on identifying and treating impairments such as abnormal joint mobility.[10,16,17] Few authors, however, discuss the importance of relating these impairments to the patient's disability. I believe that it is critical to evaluate all of the predisposing factors to the patient's disability, using a logical process, For example, "normal joint mobility" is a meaningless statement unless it is referenced to some activity, in this case normal joint mobility for the take-off phase of pole vaulting.[31] Relating the impairment to the disability would allow the assumption of limited joint mobility to be tested for causal relationship with the inability to perform a desired task. This relationship should be considered a central theme in patient evaluation.[20] Quantitative assessment of many clinical phenomena that relate to patients with LBP has not been demonstrated.[8,12-15,31,32] Reliable measurements of lumbar flexion and extension using a tape measure have been reported; however, these data are useful for understanding the magnitude of sagittal lumbar motion only.33,34 In this case study, the decision making was primarily based on the patient's inability to perform the combined movement of trunk extension, rotation, and side-bending. There appears to be no inexpensive, readily available instrument that has been reported to generate reliable and valid measurements of this combined motion. Thus, the examiner used the "quadrant position" as the evaluative test.[10,28] A second factor on which decisions were based was the patient's report of pain while I was performing graded oscillations to the spinous processes of L2-4 (ie, "motion segment testing"). Although McCombe[32] has reported that measurements of bony, spinal midline tenderness to palpation are reliable or potentially reliable" in patients with LBP, the reliability of grading passive spinal motion in patients with LBP has not been established (see article by Riddle in this issue). Because of the lack of available measures, I had to rely on the patient's perception of pain and stiffness in response to various active and passive trunk motions. This reliance on the patient's perceptions represents a limitation to this case study. The lack of measures that relate to patients who are potential candidates for manual therapy remains as an enormous barrier to the establishment of the efficacy of these treatments.

Summary

An example of the evaluation and treatment of a competitive athlete was given. An examination process that identified impairments and related them to disabilities was presented. The treatments that were performed were based on a qualitative assessment of the patient's impairment, whereas the outcome assessment was based on the patient's disability. An eclectic approach consisting of joint mobilization, prone press-up exercises, and the correction of sitting position was presented. Following two treatment sessions using these techniques, the patient's goals were achieved.

Acknowledgments

I would like to thank Daniel L Riddle, PT, and Karen Nisenbaum, PT, for their help in preparing this manuscript.

References

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