Non-Specific Low Back Pain Flexion Control Dysfunction

Where is Non-Specific Low Back Pain Flexion Control Dysfunction painful? (Body Chart)

What are the classical features of Non-Specific Low Back Pain Flexion Control Dysfunction?

Age: Can be all ages however thought to have greater prevalence in young active population adults

Gender: No variation was documented

Sport: Active individuals, flexion biased sports (hockey, horse riding, AFL, motorsports)

Where is Non-Specific Low Back Pain Flexion Control Dysfunction painful?

– Localised back pain

– Well defined

– More commonly central but can be ipsilateral/bilateral

– Can refer in the buttock and leg but uncommon

– If persistent pain and bilateral may provide evidence for Spondylysthesis and require further investigation

Characteristics of symptoms for Non-Specific Low Back Pain Flexion Control Dysfunction

– Sharp, catching pain with movement

– Aching pain when aggravated or sedentary for long periods

– Episodic in nature

– High intensity (5-8/10 VAS)

– Low frequency

– No neurological symptoms

Typical activity capability/restriction for clients with Non-Specific Low Back Pain Flexion Control Dysfunction

– Patient is often still highly active as symptoms resolve quickly

– Patients may describe completing regular activities by requiring rests to enable to pain to reduce

– Will worsen if continually provoked (ie repeated flexion – hockey)

– Reduced fluency of movements due to guarding (ie picking something up on the ground)

Behaviour of symptoms for Non-Specific Low Back Pain Flexion Control Dysfunction

Ease:

– Avoidance of flexion based activities, NSAIDs, extension-based activities, lumbar support in sitting, postural correction

Agg:

– Lumbar flexion, sitting, flexion biased combined movements, repeated movements into flexion, fast movements especially if at the end of range flexion

24-hour pattern:

– Activity dependant, likely to get better at night secondary to a prolonged period of extension

Typical history of a client with Non-Specific Low Back Pain Flexion Control Dysfunction

– Participation in activities with flexion moment (ie sitting for long periods of time)

– Previous episodes of similar lower back pain

– Often report an insidious onset // likely to be related to prolonged flexion (sitting)

– If acute onset will report a flexion biased mechanism of injury ie bending over to lift up something heavy off the group

– Will get worse with activity when aggravated (no warm-up effect)

– Enquire about activity preceding incident if no clear mechanism

Pathobiological mechanisms behind Non-Specific Low Back Pain Flexion Control Dysfunction

– Need to triage and rule out specific pathology prior to using movement patterns

– If clear then evidence supports the category of non-specific lower back pain

– Movement patterns are considered as a subcategory of non-specific lower back pain

– Only use as a pattern if nociceptive dominant

– If chronic then considers it as an impairment however inadequate to use as a primary diagnostic label. Management should then be implemented as a nociplastic dominant presentation

Proposed pathology underlying Non-Specific Low Back Pain Flexion Control Dysfunction

– Triage completed and specific pathology excluded (non-specific lower back pain)

– Compressive load on the anterior tissues of the spine (ie disc pathology)

– Tensile load on the posterior tissues of the spine (ie PIV)

– The lower back is considered to be insufficiently actively constrained

Note: Evidence supports that pathology observed on imaging does not necessarily correlate to pain/disability

Physical impairments & associated structure/tissue sources (ie P/E findings)

Local

– Hypermobility into lumbar flexion // with PPIVM

– Increased pain with lumbar movements (flexion + unilateral bias)

– Pain limited range into flexion, hypermobile if not pain limited

– Hypomobility into extension

– Stiffness with PA and unilateral PA PAIVM

– Worse with repeated movements into flexion

– Reduced lumbar lordosis in sitting

– Reduced motor control into extension // unable to get out of the aggravating position

– Reduced lumbar body schema

– Reduced local two-point discrimination

Remote

– Glute weakness

– Hip flexor weakness

– Reduced flexion range in thoracic spine and/or hips

– Reduced motor control into flexion in spine and hips

General

– Deconditioning

– Reduced muscular endurance

– Slouched posture

– Bracing and breath-holding with flexion movement

Surveys

– Oswestry Low Back Pain Disability Questionnaire validated measurement tool

Typical contributing factors to Non-Specific Low Back Pain Flexion Control Dysfunction

– Weight

– Genetics

– Physical fitness

– Hypermobility in the lumbar spine

– Participation in high-risk activities

– Sporting Technique

– History of low back pain

– Smoking

– Stress/anxiety

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability

– Need to exclude specific pathology when considering a non-specific diagnostic umbrella

– Cordea equina

– Clear neurological signs/symptoms if clinically indicated

Relevant diagnostic imaging for Non-Specific Low Back Pain Flexion Control Dysfunction

– Can be used to rule out serious pathology when indicated // note that referral for lower back pain in itself is insufficient, need to have evidence of specific pathology or neurological symptoms to consider. If non-specific back pain evidence to support patients do better without the scan

– Presence of pathology is normal and not indicative of pain/disability if the patient comes with imaging // always conduct an unbiased assessment and then compare patient presentation to the clinical findings

– MRI goal standard

Typical prognosis for Non-Specific Low Back Pain Flexion Control Dysfunction

– Often resolved within weeks

– Favourable if the first incident, with recurrence the prognosis worsens

– With the increase in psychosocial flags the prognosis worsens

High-level evidence

– Quicker return to work when positive outcome expectation

Management/treatment selection for Non-Specific Low Back Pain Flexion Control Dysfunction

Phases of rehabilitation

– Stage 1: Symptom management

– Stage 2: Reloading phase

– Stage 3: Return to full function and sport

Local

– Joint play techniques (high-level evidence)

– Mobilise into extension

– Muscle control into extension in stage 1 // start with extension bias and progress to a flexion biased position

– Muscle control into extension in stage 2

– Muscle control translation into functional/dynamic activities stage 3

– Pacing to progressively increase loading

– Taping (box tap to limit flexion)

Remote

– Abdominal strengthening/control (mid-level evidence for TA activation)

– Increase mobility into flexion at hips/thoracic

– Muscle control into flexion at hips/thoracic

General

– Rest contraindicated (high-level evidence)

– Increase physical activity (high-level evidence)

– Consider biomechanics and technique // are we able to redistribute the load somewhere else

– Postural correction into lumbar extension (ie sitting posture)

– Address contributing factors and cardiovascular fitness

– Equipment // patient population respond well to lumbar support

– Consider work set up

– Ergonomic optomisation

Pharmacological (high-level evidence) (refer as required)

– NSAIDs

– Analgesics

– Muscle relaxant

Differential diagnosis for Non-Specific Low Back Pain Flexion Control Dysfunction

Spondylolisthesis // bilateral pain, neurological symptoms

Disc pathology (especially if herniation) // flexion pattern and pain that crosses the midline

Spinal cord injuries // positive neurological or neurological symptoms

Cord equina // B&B, saddle anesthesia, bilateral symptoms

Muscle strains // dynamic assessment

Central canal stenosis // neurological symptoms, bilateral symptoms

Nerve root // positive neurological or neurodynamic findings

Cancer // subjective special questions

Ankylosing spondylitis // inflammatory special questions

References

Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

Davidson, M. and Keating, J.L., 2002. A comparison of five low back disability questionnaires: reliability and responsiveness. Physical therapy, 82(1), pp.8-24.

Hayden, J.A., Wilson, M.N., Riley, R.D., Iles, R., Pincus, T. and Ogilvie, R., 2019. Individual recovery expectations and prognosis of outcomes in non‐specific low back pain: prognostic factor review. Cochrane Database of Systematic Reviews, (11).

Krismer, M. and Van Tulder, M., 2007. Low back pain (non-specific). Best practice & research clinical rheumatology, 21(1), pp.77-91.

Luomajoki, H.A., Beltran, M.B.B., Careddu, S. and Bauer, C.M., 2018. Effectiveness of movement control exercise on patients with non-specific low back pain and movement control impairment: a systematic review and meta-analysis. Musculoskeletal Science and Practice, 36, pp.1-11.

O’Sullivan, P., 2012. It’s time for change with the management of non-specific chronic low back pain.

O’Sullivan, P., 2006. Diagnosis, Classification Management of Chronic low back pain. A mechanism based bio- psycho-social perspective.

O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), pp.242-255.