Who Benefits Most from Lumbar Strengthening Exercises?

As mentioned in the “Treatment Based Classification” section, we are less concerned with identifying the “exact cause” of low back pain as we are looking for clinical features that show a greater likelihood of success with specific treatments. Identifying “exact pain generator” is nearly impossible even with MRIs. 

So, what features do we look for to determine patients who do best with this approach? 

Unfortunately, despite lots of research on the topic, we do not have a clear “black and white” answers on this subject.

The most telling signs appear to be a positive “Prone Instability Test” and “aberrant movement.” A “Prone Instability Test” involves your physical therapist pushing on your back and identifying a painful level. Then he will have you lift your legs while holding onto a table and then push the painful vertebrae again. Pain in the first position with a relief of pain on the second test is a positive finding. The rationale for this is that your muscles are more active in the second position. This suggests if your muscles are more active in the first position, the test would not have been painful. “Aberrant movement’ is a scientific way of saying low back movement that looks funky. This may include the need to push off your thighs to stand straight from a bent forward position, a “catch” when someone bends forward or something else preventing smooth movement (i.e., the ability to bend forward and return to a fully erect position without limitation). 

Since this is a grey area, a group of experts identified the top clinical features that would indicate a patient most likely to benefit from this approach. While this is not exactly the gold standard of research, it is helpful to consider these findings in the overall context of research. Complete consensus was reached on the following signs and symptoms from a physical exam:

• Reporting feelings of the back “giving out”
• Frequent need to crack or pop the back 
• Frequent episodes
• History of catching or locking 
• Pain during activities that involve a change in position (i.e., getting out of bed)
• Increase in pain returning to standing following bending forward
• Pain with mild movements
• Difficulty sitting unsupported 
• Condition progressively worsening
• Long-term history of pain
• Frequent episodes of muscle spasms
• Temporary relief with a back brace

As with almost anything with physical therapy, all of these findings are taken into consideration of the greater clinical picture. If we think you will do best with a strengthening approach, we will begin a few exercises and closely monitor if we are making progress towards your goals. If we are not, adjustments in the exercises will be made accordingly. 

References:

1. Bialosky, Joel E. et al. “Spinal Manipulative Therapy–Specific Changes In Pain Sensitivity In Individuals With Low Back Pain (NCT01168999)”. The Journal Of Pain, vol 15, no. 2, 2014, pp. 136-148. Elsevier BV, https://doi.org/10.1016/j.jpain.2013.10.005.
2. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835-2843.
3. Fritz, Julie M. PT, PhD, ATC, Cleland, Joshua A. PT, PhD, OCS, FAAOMPT, and Childs, John D. PT, PhD, MBA, OCS, FAAOMPT, “Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy,” Journal of Orthop Sports Physical Therapy 37, no. 6 (June 2007): 290-302.
4. Koppenhaver, Shane L. et al. “Association Between Changes In Abdominal And Lumbar Multifidus Muscle Thickness And Clinical Improvement After Spinal Manipulation”. Journal Of Orthopaedic & Sports Physical Therapy, vol 41, no. 6, 2011, pp. 389-399. Journal Of Orthopaedic & Sports Physical Therapy (JOSPT), https://doi.org/10.2519/jospt.2011.3632.

Related Articles